This literature review was carried out on behalf of the Department of Health, with the aim of helping decision-makers support acute care, by moving some services out of the hospital, and into the community, to be delivered by primary care and community health services.
This is both beneficial to the health service providers in the acute setting, as more beds will be available for emergency care, and to the patients, who often have a better healthcare experience in a location that is familiar to them. A community setting, whether a care home or their own home makes it easier for friends and family to visit, and health care staff may have more time to spend with them. While acute care has the additional specialist expertise, there is often less time to be with patients.
Integrated service delivery
The review focuses on three different perspectives of integrated service delivery, from the frontline to the overall health economy:
- Micro-level – focusing on frontline personnel and how teams can work together effectively.
- Meso-level – looking at the impact of the integration on the health care organisations involved.
- Macro-level – identifying which are the best organisational models to facilitate integration.
The authors have synthesised the evidence, at each of these levels, and have made several recommendations, based on existing evidence, and highlighted the gaps where more research is needed. In particular, they have noted that there is scarce evidence for the cost-effectiveness of community health services, and this is partly because there is a paucity of data about what these services cost
Characteristics of success
Despite the lack of evidence in some areas, the authors have presented some very useful findings. At the micro-level, Table 1 defines the enabling characteristics of effective healthcare team functioning. Communication appears to be one of the fundamental requisites for successful team-working, and the authors recommend that when planning integrated services, managers build on existing, successful local collaborations, rather than creating new partnerships.
At the meso-level, the authors look at the advantages and disadvantages of different models of community services, and also federated models, – where the evidence comes from case studies, – polyclinics or GP led centres, and case management, although research shows that the latter is more effective with high-risk groups.
At the macro-level, the focus is on ownership, but there is insufficient evidence to declare which model is best, and because of the lack of data about community health services, it will take time to evaluate the benefits of one particular model.
The reference list provided at the end of this research is definitely worth following through.
Chronic conditions such as dementia, diabetes, chronic obstructive pulmonary disease, and asthma, are perfect examples where this research will be useful.
Dementia, for example, is presenting a significant burden on acute services. At present, a quarter of hospital beds are occupied by people with dementia, who require specialist care, but not necessarily within a hospital setting. With the appropriate support, informed by this research, care can be delivered in the community.
This research has highlighted several areas where there are still research gaps, but it is still a very interesting piece of research, and there is much to learn from it. It is definitely worth reading, and seeing which areas are most applicable to your departments. Because there are still unknowns, it might be useful to discuss this paper with your networks to see how you can apply the evidence-base together with your service partners.
Bramwell D, Checkland K, Allen P, Peckham S. (2014) Moving services out of hospital: Joining up general practice and community services. PRUComm: Policy Research Unit in Commissioning and the Healthcare System: London School of Hygiene & Tropical Medicine