Reconfiguring whole trusts

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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 whole trusts.

Proposals reviewed by NCAT

  • Moving towards treating patients with less serious conditions or with a lower level of clinical risk, for example:
    • moving from accident and emergency care to an urgent care centre or minor injury unit
    • moving from acute / emergency medicine to non-acute or rehabilitation
    • moving from consultant-led obstetrics to a midwife-led birthing unit.
  • Concentrating services through ‘swaps’ between hospital sites, for example:
    • a ‘swap’ of obstetrics for acute surgery
    • a ‘swap’ of stroke for acute surgery.

Key drivers of whole trust reconfigurations

Finance and workforce were the primary drivers of this type of reconfiguration.

Context and relevant policy

  • Greater specialisation of clinical staff and equipment in hospitals.
  • Scarcity of skilled specialist staff and limited budgets.
  • Limits on junior doctors’ working hours.
  • United Kingdom’s low numbers of consultant doctors compared with other developed countries.
  • Clinical co-dependencies between different services.
  • Department of Health policy, in particular Keeping the NHS local – a new direction of travel.

The current evidence base

There is little evidence to guide whole hospital reconfiguration, and much of the evidence that does exist is out of date.

The available evidence suggests that smaller hospitals in England are not inherently less safe or less efficient. However, there are good arguments on quality grounds for centralising some local hospital services or at least providing them on a more networked basis.

Active participation in clinical networks can help ensure that patients receive the best quality of care as close to where they live as possible while at the same time addressing workforce pressures.

A major challenge for small hospitals is to move from a consultant-led to a consultant-delivered model of care. The use of a national tariff disadvantages smaller providers. The current pressures to expand the number of consultant staff to provide higher-quality, consultant-delivered care will increase their fixed cost base and magnify this problem.

Relevant college guidance

Big is not necessarily better. Outcome measures for acute care are being developed but, with the possible exception of major trauma, we are not at the stage of providing robust evidence.

(Academy of Medical Royal Colleges 2007, p v)