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The reconfiguration of clinical services

What is the evidence?

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).

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).