The reconfiguration of clinical services is an important but insufficient approach

In a recent editorial for the BMJ, Nigel Edwards argues that ‘the quality of debate about the role of hospitals has improved’. He cites the work of the Royal College of Physicians (RCP) Future Hospital Commission and the NHS five year forward view. Both have moved away from an all-or-nothing approach to the future of acute hospital care and envisage hospitals that are more integrated with primary and tertiary care.

Today The King’s Fund hopes to enhance the quality of that debate even further with the publication of a major report laying out the evidence available to help guide the reconfiguration of hospital services. The evidence supports the direction of travel suggested by NHS England and the RCP, in particular that there are increasing opportunities to sustain services in smaller hospitals. We need to grasp these opportunities if we are to provide a model of hospital care that recognises the huge demographic shift currently under way. 

We argue that hospitals are part of an interconnected web of care stretching from the patient’s home to the most specialist tertiary-level service. Clinical networks and new technologies offer opportunities to strengthen that web and deliver more co-ordinated care. Those planning services need to look across that web to ensure the most efficient distribution of services, to remove duplication, and to ensure that patients receive the right care in the right location at the right time.

However, our research highlights major gaps in the evidence. For example, saving money is one of the top two reasons given for reconfiguration, yet there is no evidence that reconfiguration will save significant sums of money either through centralising hospital services or replacing them with community services.  

Workforce is the other primary driver for service change – for example, the desire to move from a consultant-led to a consultant-delivered service. While there is strong evidence to support the benefits of more consultant-delivered care, particularly for high-risk patients, there is little evidence to say how many senior staff are needed, of what type and for what time periods. 

There is good evidence to support the centralisation of many specialist services. For example, there is evidence that outcomes for vascular surgery can be improved through centralisation. However, the benefits rely on much more than a simple link between volume and outcomes. The ways of working within and across specialties can be just as important (a message that is true for all services, specialist or not). For example, systematic use of the WHO surgical safety checklist (Haynes et al 2009, de Vries et al 2010) can reduce complication rates from surgery by over a third and deliver reductions in absolute mortality that are comparable with those achieved from the reconfiguration of stroke services in London (Morris et al 2014). 

Above and beyond this we need to recognise that hospitals play only a minor part in determining population health outcomes. For example, a recent major randomised control trial of patients at high risk of cardiovascular disease, including stroke, showed that following a Mediterranean diet supplemented with nuts nearly halved the rate of stroke in this group (Estruch et al 2013). If this happened in London, many more lives would be saved than was achieved through the reconfiguration of stroke services. As we say in our report, the reconfiguration of health services is an important but insufficient approach to improving health care and outcomes.

The report referred to in this blog draws on research funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research Programme (project number 12/5001/59).

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Comments

#307329 Peter Barrett
Retired Chair IRP

Candace, I thought this was a thorough and insightful piece of work. I suppose that recording the numbers of consultants et al said to be working is important but it, in my experience, does not necessarily reflect the numbers actually doing the work. Congratulations to you and your team for producing a paper that will stimulate a lot of discussion.
Peter

#307546 Roger Steer
Director
Healthcare Audit consultants ltd

Is it a coincidence that the debate has improved as the old regime has moved on. An old regime not noted for debating skills but assertiveness.
But it will be no comfort if as a result nothing happens.
The big reason that reconfiguration doesn't work, and many health economies are in distress are the punitive costs of PFI investments required to facilitate change. But the solution is not to stop investment but to share the pain by moving to reimbursement of actual cost of capital in the tariff via MFF and to move to an Investment Bank approach for the NHS.
But that's another debate.
PS Thank you Peter for all your good work at the IRP. We relied on your good sense in our work advising local authorities.

#335535 Dr Philip McMillan
Hospital Clinician

I have observed the reconfiguration of clinical services in my local Trust and have come to the conclusion that it is just a numbers game. Limited resources and lack of clarity make an awful combination.
Sometimes the most obvious thing is what needs to be done. Until we either properly deal with the issue of 7 day working or legislate that people do not get sick on weekends, we will go in circles.
I can see how to make a 25% saving by doing the right things. However it would not be easy and the potential saving should be invested back in the staff who will have to be doing the hard graft.
Very few of the decision makers understand how difficult it is to work on a sick patient at 3am Saturday night.
Deal with the big obvious challenges and everything will fall in place.

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