Outpatient services and primary care: scoping review, substudies and international comparisons

Abstract

AimThis study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.Findings from the scoping reviewEvidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for 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. One promising development 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 substudiesBecause of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches 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. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.ConclusionsFor many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. 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. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.FundingThe NIHR Health Services and Delivery Research programme.

Community hospitals and their services in the NHS: identifying transferable learning from international developments – scoping review, systematic review, country reports and case studies

“…Second, previous work in a related area provides evidence of organisational structures that are comparable to community hospitals as defined in the present study in Finland. 20,106 Third, consultation with members of the steering group for this project identified unpublished reports on organisational structures that are comparable to community hospitals as defined in the present study in Italy. Starting from this sample of countries, a further consideration for country selection was comparability to the English NHS on key characteristics while acknowledging differences in countries' political, societal and cultural contexts within which health service delivery systems operate, alongside variation in demographic and geographical features.…”

“…6 There are also concerns about the perceived high costs of hospital care and, consequently, health-care systems have been experimenting with new ways of shifting specialist services from hospital into the community as a means to increase the accessibility of services and responsiveness of the system, and, potentially, to reduce costs. 20,105,106 In England, a policy focus on moving health care closer to people's homes has led to renewed interest in community hospitals and the potential role they can have in delivering more integrated care at the local level. 18 Countries such as Italy and Norway are implementing community hospital-type delivery models in an effort to reduce reliance on acute hospital care and to provide more integrated care within the community.…”

The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis

“…172 Earlier models of providing specialist care in the community include interventions that involve the transfer of services where primary care substitutes for secondary care [e.g. GPs with specialist interests (GPwSIs) 71,173,174 or the relocation of services from secondary care to primary care settings). [174][175][176][177][178] More recently, the ways in which specialist care is being implemented in primary care go beyond the 'drag and drop' approach of simply relocating a hospital outpatient clinic into a community setting; instead, methods that put education at the core alongside the redesign of the patient pathway and/or the role of the professional are becoming more established.…”

“…GPs with specialist interests (GPwSIs) 71,173,174 or the relocation of services from secondary care to primary care settings). [174][175][176][177][178] More recently, the ways in which specialist care is being implemented in primary care go beyond the 'drag and drop' approach of simply relocating a hospital outpatient clinic into a community setting; instead, methods that put education at the core alongside the redesign of the patient pathway and/or the role of the professional are becoming more established. 179 Examples included in a recent The King's Fund report, Specialists in Out-Of-Hospital Settings: Findings from Six Case Studies, 179 are outreach clinics jointly staffed by hospital consultants and other health-care professionals, consultant-run e-mail and telephone helplines, consultant participation in MDT meetings, consultant-run education sessions and consultants supporting staff to work in extended roles.…”

“…164,181 In general, studies reporting on the transfer of care from secondary to primary care have reported that the quality of care achieves an acceptable standard. 71,173,174 The safety of diagnostic services transfer is equivocal; a literature-mapping exercise 175 found evidence that the quality (including diagnostic accuracy and the appropriateness of test ordering) and safety of diagnostic service provision in the community is mixed.…”