This new report from the King’s Fund is timely, given the emphasis on the need for transformation in current policy (for example, the new care models proposed in the Five Year Forward View in England).
The climate of financial pressures alongside increasing demand is driving the need for change at a system level. However, despite the number of reconfiguration programmes which have completed or are still underway, the evidence base is relatively underdeveloped, presenting a challenge to new programmes.
The King’s Fund have based their report on:
- a synthesis of 108 NCAT (National Clinical Advisory Team) reconfiguration reviews between 2007 and 2012;
- a comprehensive literature search, using a range of methods including database searching, handsearching journals, citation searching and consultation with experts in the field.
The report builds on research undertaken for the National Institute of Health Research, due to be published soon, and aims to summarise evidence, guidance and policy relating to reconfiguration of services in primary, secondary and tertiary care. The authors acknowledge that the report doesn’t cover all clinical specialties – and reflects the focus of the reconfigurations reviewed by NCAT.
The findings are presented by service and organised according to the various drivers (workforce, quality, access, cost, technology – these have been updated from an earlier report by Imison). The report recognises there have been very few evaluations of significant change programmes – for example, hospital based services are rarely tracked and monitored for financial impact. There are some critical success factors identified including the involvement of clinicians, the importance of an empowering culture and the use of proven improvement tools and processes. It’s quite a long report and I’ve attempted to pick out a few highlights here.
- Whole Trust reconfiguration: earlier reconfigurations have focused on moving services between sites and shifting from consultant-led services (e.g. from obstetrician-led to midwife-led units), typically driven by workforce and cost pressures. The evidence suggests that smaller hospitals are not necessarily less safe but there are good arguments for centralisation (the concept of “distance decay”, outlining risks associated with greater distance, is covered); the current tariff is a disincentive for smaller hospitals, due to higher fixed costs. There is no clear link between hospital size and outcomes – economies of scale are seen at around 200 beds and diseconomies start at around 650 beds; however, there are “economies of scope” such as links between specialties and optimal use of expensive equipment and there is some evidence to suggest that centralising specialist services improves quality outcomes. The role of clinical networks is emphasised as a potential solution for addressing workforce issues.
- Community-based services: reconfigurations have tended to focus on shifting care closer to home, intermediate care capacity, and consolidating primary care services. There is an assumption that a significant proportion of hospital beds are occupied by patients who could be better managed in community settings or at home and interventions are often based on the assumption that shifting care closer to home will reduce unplanned care and deliver savings – however, the evidence base on interventions to reduce admissions is mixed and there is no evidence to support the delivery of savings. However, there does seem to be evidence to suggest that quality outcomes can be improved. The report suggests some reasons why community initiatives may not have the expected impact: poor implementation; supply-induced demand; and a piecemeal rather than system approach to delivering change.
- Mental health services: the evidence supports the argument that community models deliver improved outcomes, satisfaction, engagement and medication adherence. Alternatives to admission, such as crisis homes, seem to offer higher satisfaction and similar clinical outcomes. Whilst savings have been generated from land sales, the report suggests that ongoing savings are not achievable. Access to early intervention services are highlighted as effective, particularly for detecting and treating psychosis. One of the key drivers for reconfiguration in future is likely to focus on workforce, due to forecasted shortages of consultants and nurses.
- Accident and emergency and urgent care services: the report emphasises the importance of senior medical staff presence in A&E seven days a week, also pointing to professional guidance. A&E services will also need: rapid access to critical care; 24/7 support from diagnostics; rapid access to specialist medical staff; access to liaison mental health services; and involvement in a formal trauma network. Many reconfigurations focus on centralising A&E functions, however the evidence base is very limited; there is some evidence to suggest that increased distance may impact outcomes for severely ill patients.
- Maternity services: reconfigurations have tended to focus on concentrating consultant-led services across fewer sites and moving towards midwife-led units. The evidence base suggests that for high risk women, the presence of senior obstetricians improves outcomes, however, there is no evidence on what the number should be. The report authors found no evidence to suggest an association between outcomes and the size of obstetric units. Midwife-led units are safe for low-risk women; however, there may be concerns about financial sustainability and staff capacity.
The report also summarises the evidence base relating to acute medical services; acute surgical services; elective surgical care; trauma; stroke care; specialist vascular surgery; neonatal services; and paediatric services.
This is a valuable report, summarising the state of the evidence base on reconfiguration, and will be essential reading for decision makers involved in reconfiguration. The synthesis of NCAT reports is particularly helpful – in my experience, these are scattered across multiple sources, taking time to track down. One of the key messages from the report is the lack of robust evidence on the impact (financial and patient outcomes) of reconfiguration pointing to the need for more research and evaluation to be built into reconfiguration programmes. There is also a need for more knowledge sharing – initiatives such as the Future Hospitals programme, led by the Royal College of Physicians, may act as a useful conduit for sharing experience and lessons.
The report notes that 40% of reconfiguration proposals were not implemented as planned suggesting that the dynamics of local health systems may be even more complex than anticipated. Commissioners involved in or planning large scale reconfigurations may wish to consider:
- Are your expectations valid and realistic? Have you conducted robust comparative analysis of different models (from a quality and financial perspective)?
- Have you explored opportunities to co-produce models with all your key stakeholders?
- How are you going to measure the impact of your programme? Early involvement of independent researchers can result in a more robust evaluation.
- How will you disseminate and share the important learning from your programme – such as, overcoming barriers/challenges, critical success factors?
- What can you learn from other reconfigurations? What lessons apply to your local context?
- Have you fully engaged with clinicians at all levels and across all relevant disciplines?
- How are you going to maintain momentum with stakeholders in between key milestones of the programme?
Imison C et al, The reconfiguration of clinical services: what is the evidence? Kings Fund, 2014.