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 main findings of the report.
The evidence base
The reconfiguration of clinical services represents a significant organisational distraction and carries with it both clinical and financial risk. Yet those who are taking forward major clinical service reconfiguration do so in the absence of a clear evidence base or robust methodology with which to plan and make judgements about service change. In particular:
- Evidence to support the impact of large-scale reconfigurations of hospital services on finance is almost entirely lacking.
- Evidence on the impact on quality is mixed, being much stronger in relation to specialist services than other areas of care.
- Evidence on the importance of senior medical and other clinical input to care is strong, particularly for high-risk patients; however, there is uncertainty about how many senior staff are needed, of what type, and for what time periods.
- Evidence suggests that some services can be provided safely through the use of non-medical staff.
- Technology offers opportunities to sustain local access to some services that previously might have been centralised, although the evidence on this is still developing.
- Gaps in the evidence will often lead to different and sometimes conflicting views on the best way of providing safe, high-quality services within available budgets. This is particularly the case for non-specialist services where the evidence on the net benefit of centralisation is often lacking.
Clinical senates and those leading local research, such as academic health science networks, should be encouraging evaluation of service reconfigurations and sharing the learning that emerges. For any major service change, there should be a routine post-project financial and clinical evaluation, conducted independently where changes are particularly innovative or complex.
Implications for the NHS
Reconfiguration is an important but insufficient approach to improve quality. It should be used alongside other measures to strengthen delivery of care and to instil an organisational culture of improvement.
There are new and evolving opportunities to sustain local access to services, particularly for lower-risk patients, with more flexible use of current staff and greater use of non-medical staff and digital technologies. However, shortages of key staff, for example, midwives and specialist nurses, may limit this approach as a solution. It is also anticipated that there will be a significant increase in the consultant medical workforce, and proposals should take this into account or risk designing tomorrow’s services within today’s constraints. Workforce planners need to work with service planners to support the development of staffing for these new models of care.
The local context and the specialty-specific balance between access, workforce, quality, finance and use of technology need to be the deciding factors in determining how local services are configured, recognising that there is no ‘optimal design’. To maximise the likelihood of success, proposals should be underpinned by detailed workforce and financial plans with supporting service improvement strategies.
The balance between access, workforce, quality, finance and technology will play out differently for patients with different levels of clinical risk and complexity. Systems and processes to accurately triage and rapidly transport patients should be a key part of any proposal.
Any proposal needs to have come out of a process with strong engagement from clinicians, public and politicians.
No hospital is an island. 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, but 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.