The reconfiguration of clinical services

What is the evidence?
Comments: 3
The reconfiguration of clinical services continues to generate public and political controversy, locally and nationally. Given significant financial and workforce constraints, now and in the future, pressure to reconfigure services is only likely to increase. But what are the key drivers of reconfiguration and what is the evidence to underpin it?

This paper aims to help those planning and implementing major clinical service reconfigurations ensure that change is as evidence-based as possible. It investigates the five key drivers – quality, workforce, cost, access and technology – across 13 clinical service areas, summarising the research evidence and professional guidance available in each. It builds on a major forthcoming analysis of reviews of service reconfigurations commissioned by the National Institute of Health Research and conducted by the National Clinical Advisory Team (NCAT). 

The reconfiguration of clinical services

Print copy: £15.00 | Buy

No. of pages: 138

ISBN: 978 1 909029 43 9

Key findings 

  • The evidence did not suggest that reconfiguration, including moving to a more community-based model of care, will deliver significant savings.
  • Improvements in quality can be achieved through reconfiguration, but these are greater for specialist services, and service improvement strategies may deliver more significant improvements.
  • Availability of experienced medical and nursing staff is shown to be important, but there is limited evidence on how many staff are needed, of what type and over what time period.
  • There is no ‘optimal design’ for local services; their configuration will depend on the local context and the specialty-specific balance between access, workforce, quality, finance, and use of technology. 
  • The balance between access, workforce, quality, finance and technology will play out differently for patients with different levels of clinical risk and complexity. 
  • Those planning services need to look across the full care spectrum to ensure the most efficient distribution of services, to remove duplication, and to ensure that patients receive the right care, in the right place, at the right time. 
  • Proposals should be underpinned by detailed workforce and financial plans with supporting service improvement strategies.

Policy implications 

  • More resources need to be invested (locally and nationally) in evaluating the impact of service reconfiguration, with comparative analysis of different models of care – and particularly their impact on quality and cost.
  • Proposals need to emerge from a process based on strong engagement from clinicians, the public and politicians.

Funding acknowledgement

This publication 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

#307409 Michael Crawford
Consultant Medical Oncologist

I came upon this item when I returned to my office after giving the Trust’s monthly lecture. My subject was “Poor country folk and cancer.” It drew on published work that I have done with a team from the University of East Anglia.
Impaired access to diagnosis and treatment could be demonstrated very strongly for older and poorer people. Especially for poorer people services tended not to be used if they were further away from the residence; this applied strongly to the specialist services like thoracic surgery and radiotherapy but also to more local services in the acute general hospital and even distance to the GP surgery had an effect in respect of those who lose out completely, being diagnosed as “metastatic cancer site unspecified” (ICD10 C80).
When looking at how services are configured the question that should be addressed with the highest priority is: “How can equity of access be assured for people who live in deprived neighbourhoods compared with their better off compatriots?” I suggest comparing service use among those living in super output areas of Index of Multiple Deprivation >20 with those with IMD <10.
It is also poor practice simply to compare historical outcome data from a specialist centre with those from a general hospital. One ought really to do randomised controlled trials of specialist versus standard services. Failing that one has to eliminate bias of choice. This occurs when socioeconomically favoured patient travel for treatment to a distant service of high regard. Such patients tend to be those who do are predisposed to do well, leaving their poorer, prognostically less favoured, neighbours to use the local hospital. The results of the comparison of the hospitals are meaningless. It would be better to compare the outcomes of patients who live neat the specialist service with those who live near the standard service irrespective of where they are treated. That way, the specialist service can shine by demonstrating good results for its less well favoured local residents.

#310693 Minesh Khashu
Consultant Neonatologist & Prof. of Perinatal Health
NHS

I think we ought to compare reconfiguration in terms of a structural change versus process redesign. Significant improvements in quality of care can be achieved by increased use of automation and technology which is currently available and used in other sectors.

It is also worth exploring a model of health and social care involving a single organisation covering a geographical area and population of 1-2 million and encompassing what today may be 1-2 acute care providers, 1-2 community trusts, sets of GP practices, local councils etc. This is the only way patients can get seamless care and we can make a shift to preventive health and wellness paradigms.

#511302 Margaret Coles
Physiotherapist
Movingtherapy

That's why prevention and promotion of health and well-being should be the first priority of all sectors of health care. The key factor is activity. in my opinion ( obviously) physiotherapists skilled in movement and motivation should play key roles in any strategy of the future of health care and across all sectors.

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