‘Moving care into the community’ is a prominent feature of NHS policy. But when does it make sense, and when are services better provided in hospitals?
In this project we examined this question as it relates to outpatient clinics.
First we carried out a scoping review, updating an earlier review (PDF) which we completed in 2006.
Second we carried out a set of substudies looking at different types of intervention designed to improve effectiveness or efficiency of outpatient referrals. These included referral management centres, schemes to promote in-house reviews of referrals in general practices, financial incentives to reduce referrals, and consultants who have contracts to work directly for primary care organisations.
Finally, we examined innovative approaches to delivering services at the primary-secondary interface in a set of high income countries. We synthesised these findings to identify the potential for innovative models of care to be rolled out more widely.
Findings from the Scoping Review
With appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care.
Relocating specialists to primary care settings is popular with patients.
Increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value.
However, for all these approaches there is very limited information on cost-effectiveness. We do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches.
The most promising approach is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.
Findings from the Substudies and International Comparisons
Referral management centres encountered practical and administrative challenges and had difficulty getting buy-in from local clinicians.
The effectiveness of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals, is uncertain.
The effectiveness of schemes, which provide a systematic review of referrals within GP practices, were also uncertain, but they appeared to have a greater educational value.
Consultants, who held contracts with community-based organisations rather than with hospital trusts, were found to be constrained in their roles due to their idiosyncratic nature, a lack of clarity, challenges to professional identity and a lack of opportunities for professional development.
Common approaches by other countries to reform activity at the primary-secondary care interface included: the use of financial mechanisms and incentives; the transfer of work to primary care; the relocation of specialists; and, the use of guidelines and protocols. However, apart from the financial incentives, there is a lack of robust evidence on the effect of these approaches.
For many conditions, high-quality care in the community can be provided and is popular with patients. However, there is little conclusive evidence on the cost-effectiveness of the provision of more care in the community.
Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs.
The reconfiguration of services can often be introduced without adequate evaluations, so it is important that new NHS initiatives collect data to show whether or not they have added value, and improved quality and patient and staff experience.
Community hospitals could be better integrated into the NHS England healthcare system to offer an effective and efficient alternative to acute hospitals and to provide health and social care closer to people’s homes. However, there is limited evidence on the cost effectiveness of community hospitals.