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

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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:


Bob Hodges

Locality Commissioning Exec Chair (Gloucester),
Gloucestershire CCG
Comment date
13 January 2015
Being a bit more 'low brow' than Craig, I'd paraphrase the great Kenneth Williams on the issue of 'Specialists':

"The problem with modern medicines that everyone's now a 'specialist'. People are getting better and better at less and less. Eventually, someone will be SUPERB.........at NOTHING."

Craig Wakeham

GP & Commissioner,
Cerne Abbas Surgery & Dorset CCG
Comment date
23 October 2014
Karl Popper wrote: "Philosophers should not be specialists. For myself, I am interested in science and in philosophy only because I want to learn something about the riddle of the world in which we live, and the riddle of man’s knowledge of the world. And I believe that only a revival of interest in these riddles can save sciences and philosophy from narrow specialisation and from an obscurantist faith in the expert’s skill, and in his personal knowledge and authority; a faith that so well fits our ‘post-rationalist’ and post-critical’ age, proudly dedicated to the destruction of traditional rational philosophy, and of rational thought itself." I have come to believe the same of doctors, or at least the pre-eminence of the specialist in the 'system'. The reality of the day-to-day system in the NHS overlooks the role of the generalist and when we are 'seen' we are all to often denigrated. It is far easier working in the realm of the 'knowable' that the complex and often chaotic lives that we try to support in primary care.

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