Specialists in out-of-hospital settings: Findings from six case studies

Demographic changes, technological advances and the changing pattern of disease are pushing up the numbers of patients with complex needs who require treatment in the community. But outside hospital, the resources and expertise are often not available to treat them, and patient care can be disjointed as different parts of the system fail to understand each other. In response, consultants in some areas of England are developing services that link secondary, primary, community and social care professionals.

The King’s Fund visited six services where consultants are delivering or facilitating care outside hospital. This report presents the findings from those visits as case studies. It identifies key characteristics and challenges to this way of working and seeks out evidence of the benefits to patients and the NHS more broadly.

Key findings

• The case studies revealed huge potential in consultants working with primary, community and social care colleagues to improve the diagnosis and treatment of patients outside hospital.
• Well-designed services of this type can help patients better manage their chronic conditions and can improve patient experience, care co-ordination, and waiting times. The benefits relate mainly to the quality of care rather than cost.
• A central part of the consultant’s new role is education and training - advising and supporting primary and community staff. 
• Taking a population health-based approach to designing services is also key.
• We found no data on the wider cost implications of this approach. Robust economic evaluation should be embedded into future service designs.

Policy implications

• Strong partnerships between consultants and commissioners and transition funding are key to getting new initiatives off the ground.
• Commissioners must develop new joint tariffs, financial incentives and collaborative funding models that motivate hospitals to keep activity out of their clinics rather than pulling it in.
• New out-of-hospital service models must offer placements and training posts to prepare the future workforce to work in a more integrated system.
• As activity moves out of hospital resources must be made available to fund extra capacity in the community.

Case studies and interviews

Read about the case studies in more detail, and watch interviews with specialists from each of the services:

• Portsmouth and South East Hampshire diabetes service
• Leeds interface geriatrician service 
• Imperial child health general practice hubs 
• Sunderland dermatology and minor surgery service
• Haywood rheumatology centre
• Whittington respiratory service