The reconfiguration of clinical services report provides new insights into the drivers of reconfiguration and the underpinning evidence. It builds on a major analysis, commissioned by the National Institute for Health Research (NIHR), of reviews of service reconfigurations conducted by the National Clinical Advisory Team (NCAT).
This page summarises the report's findings on the reconfiguration of community-based services.
Proposals reviewed by NCAT
- Developing primary care services and community-based services – often as part of whole system reconfiguration
- Changes to intermediate care beds – opening or reopening, or providing on fewer sites
- Consolidating primary care services
Key drivers of community service reconfiguration
Cost, workforce, national policy and access were the primary drivers of this type of reconfiguration.
Context and relevant policy
- Use of inpatient beds by patients who could be cared for in an alternative setting.
- 2014/15 to 2018/19 planning guidance and the Better Care Fund encouraging a reduction in emergency admissions.
The current evidence base
A significant proportion of hospital beds are occupied by frail older people and people with long-term conditions who would be more appropriately cared for in the community. For some conditions, admissions can be avoided with more proactive care and, in many cases, length of stay could be reduced if there were more services to support rehabilitation and discharge. This would deliver a much better patient experience.
However, there is a lot of evidence to suggest that it can be hard for community-based initiatives, including changes to primary care, to significantly reduce hospital admissions. Delivering improvement seems to require new ways of working across a system, including within hospitals, supported by good continuity of primary care. Even with successful implementation, there is little evidence to suggest that more community-based models of care will generate significant savings. Future workforce projections also present challenges to community-based models of care.
Why do community initiatives often fail to have the impact anticipated?
Poor implementation is a key obstacle to community-based initiatives achieving significant impact on rates of admission. There are also risks of supply-induced demand.
The key to reducing the use of acute beds lies in changing ways of working across a system, including changes within hospitals, rather than piecemeal initiatives.
Relevant college guidance
The Royal College of General Practitioners (RCGP) and the Royal College of Nursing (RCN) are broadly supportive of the principle of delivering more care in community rather than acute settings. The RCGP has argued for improving access and quality through the federation of general practices.
In 2006 the RCGP and Royal College of Physicians issued a joint statement about making the best use of doctors’ skills through a balanced partnership between specialists and generalists to better manage long-term conditions and support the ‘care closer to home’ agenda. A policy briefing from the RCN outlined findings from international studies to support shifting services from the acute to the community setting.