NIHR Signal Transfer of some hospital outpatient services to general practice is effective, but costs are unclear

Published on 19 July 2016

This NIHR funded review strengthens evidence that transferring some hospital outpatient services to general practice is beneficial and liked by patients. It highlights a number of promising service configurations that could make NHS outpatient care more efficient. These include giving GPs direct access to some diagnostic tests and investigations giving specialist advice to GPs by phone or email. Where expertise is available, the report found that GPs performing minor surgery and providing long term follow up for chronic diseases were also effective.

This was an update to a 2006 review, which had similar findings. However, economic evaluations of the strategies were rarely reported, and community care may not necessarily be cheaper. If care is transferred to the community, the views of patients and the effect on overall costs are also important considerations.

Transfer of some hospital outpatient services to general practice is effective, but costs are unclear

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Why was this study needed?

In England, there is wide variation in referral rates from GPs to specialist hospital outpatient services which imply some overuse or underuse of specialist care. At the same time, policy and practice changes have shifted services from hospital and seen more care provided closer to home.

This review aimed to inform NHS policy and practice on how to improve hospital outpatient services. It follows a prior 2006 review which found that transferring care from hospital clinics to general practice, and improving general practice referral behaviour, made outpatient services more efficient and effective. Relocating specialists to general practice and developing joint working arrangements between hospital and general practice were found to be ineffective strategies.

The NIHR funded this update review to see if there was new evidence for general practice interventions designed to improve the effectiveness and efficiency of hospital outpatient service in the NHS. It also aimed to look at the impact of such schemes on staff, patients and healthcare costs.

What did this study do?

The review was a large and complex overview of evaluations using different methods of a wide range of interventions and service models. It was described as a scoping review, one which aims to map the key concepts underpinning a research area and to look at the evidence available.

The review identified 184 observational studies on primary care strategies designed to improve the effectiveness and efficiency of outpatient services. Studies were selected if interventions were transferable to the NHS, although not all were carried out in the UK.

Five main service models were reviewed: transfer of care to GPs, relocation of care (specialists working in community settings), liaison (e.g. joint care), professional behaviour change (e.g. changing GP referral practices) and patient behaviour change. Studies had to report the impact on specialist or hospital, rather than just describing the service.

Studies varied widely in quality and most did not assess the cost-effectiveness of the strategies so this remains unclear.

What did it find?

The update review found further evidence that transferring some outpatient services to general practice is beneficial and popular with patients. The findings are below.

  • Minor surgery can be safe and effective in general practice, if the person performing the surgery is skilled and trained (six studies).
  • Follow-up can be carried out effectively in general practice as an alternative to hospital outpatients, providing practitioners have adequate training and support (13 studies).
  • GPs can make effective use of direct access to a wider range of diagnostic tests and investigations, especially when combined with referral protocols (25 studies) However, comparative costs for providing these services in the community compared with in hospital are lacking.
  • In some cases giving GPs direct access to specialist services has clear benefits (e.g. audiology for hearing aids) whereas others are less certain (e.g. physiotherapy) as they can increase demand though this may be addressed by agreeing local pathways (seven studies).
  • Specialists providing care in premises outside of the hospital was popular with patients. Specialists generally see fewer patients than they would in an outpatient setting, with many needing to be seen again in hospital. Cost-effectiveness is unclear (four studies).
  • If GPs have specialist support available, such as advice by email or phone, it may help to reduce outpatient referrals (eight studies).
  • Shared care between specialist and community care teams can be effective, particularly in mental health, but there is limited evidence on cost-effectiveness (eight studies).

What does current guidance say on this issue?

There are no NICE recommendations for delivery of hospital outpatient services, however some NICE guidelines on chronic disease management, such as chronic obstructive pulmonary disease, touch on service delivery arrangements between primary and secondary care.

NHS England’s 2014 Five Year Forward Plan sets out a new direction for the NHS, including how health services need to change and what this will look like. The plan includes improving integration between GPs and hospitals, with more care delivered locally but some services in specialist centres for people with multiple conditions. It also suggests increased joint working between GPs and specialists which can be of substantial educational value.

What are the implications?

This review highlights a number of promising service alterations which may improve the effectiveness of NHS outpatient services. However, evidence is lacking on the cost-effectiveness of greater care provision in the community.

Some studies suggested transferring care to the community may increase the cost of care, with possible reasons including greater demand as a result of new services improving care supply and addressing previously unmet needs.

Evidence suggests transferring care to the community can be justified where considerable importance is placed on patient convenience in relation to NHS costs, or where community care can reduce overall care costs.

This was a broad and high-level review. There may be different emphases and findings relevant to particular clinical specialties or patient groups which cannot be fully analysed here. This review however provides useful pointers around promising interventions and highlights areas where more research is needed.

Citation and Funding

Winpenny E, Miani C, Pitchforth E, et al. Outpatient services and primary care: scoping review, substudies and international comparisons. Health Serv Deliv Res. 2016;4(15).

This project was funded by the National Institute for Health Research Health Services and Delivery Research programme (project number 12/135/02).

Bibliography

NHS England. Five Year Forward View. London: NHS England; 2014.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. CG101. London: National Institute for Health and Care Excellence; 2010.

Roland M, McDonald R, Sibbald B. Outpatient services and primary care: a scoping review of research into strategies for improving outpatient effectiveness and efficiency. Southampton: National Institute for Health Research Trials and Studies Coordinating Centre; 2006.

Winpenny EM, Miani C, Pitchforth E, et al. Improving the effectiveness and efficiency of outpatient services: a scoping review of interventions at the primary-secondary care interface. J Health Serv Res Policy. 2016.

Why was this study needed?

In England, there is wide variation in referral rates from GPs to specialist hospital outpatient services which imply some overuse or underuse of specialist care. At the same time, policy and practice changes have shifted services from hospital and seen more care provided closer to home.

This review aimed to inform NHS policy and practice on how to improve hospital outpatient services. It follows a prior 2006 review which found that transferring care from hospital clinics to general practice, and improving general practice referral behaviour, made outpatient services more efficient and effective. Relocating specialists to general practice and developing joint working arrangements between hospital and general practice were found to be ineffective strategies.

The NIHR funded this update review to see if there was new evidence for general practice interventions designed to improve the effectiveness and efficiency of hospital outpatient service in the NHS. It also aimed to look at the impact of such schemes on staff, patients and healthcare costs.

What did this study do?

The review was a large and complex overview of evaluations using different methods of a wide range of interventions and service models. It was described as a scoping review, one which aims to map the key concepts underpinning a research area and to look at the evidence available.

The review identified 184 observational studies on primary care strategies designed to improve the effectiveness and efficiency of outpatient services. Studies were selected if interventions were transferable to the NHS, although not all were carried out in the UK.

Five main service models were reviewed: transfer of care to GPs, relocation of care (specialists working in community settings), liaison (e.g. joint care), professional behaviour change (e.g. changing GP referral practices) and patient behaviour change. Studies had to report the impact on specialist or hospital, rather than just describing the service.

Studies varied widely in quality and most did not assess the cost-effectiveness of the strategies so this remains unclear.

What did it find?

The update review found further evidence that transferring some outpatient services to general practice is beneficial and popular with patients. The findings are below.

  • Minor surgery can be safe and effective in general practice, if the person performing the surgery is skilled and trained (six studies).
  • Follow-up can be carried out effectively in general practice as an alternative to hospital outpatients, providing practitioners have adequate training and support (13 studies).
  • GPs can make effective use of direct access to a wider range of diagnostic tests and investigations, especially when combined with referral protocols (25 studies) However, comparative costs for providing these services in the community compared with in hospital are lacking.
  • In some cases giving GPs direct access to specialist services has clear benefits (e.g. audiology for hearing aids) whereas others are less certain (e.g. physiotherapy) as they can increase demand though this may be addressed by agreeing local pathways (seven studies).
  • Specialists providing care in premises outside of the hospital was popular with patients. Specialists generally see fewer patients than they would in an outpatient setting, with many needing to be seen again in hospital. Cost-effectiveness is unclear (four studies).
  • If GPs have specialist support available, such as advice by email or phone, it may help to reduce outpatient referrals (eight studies).
  • Shared care between specialist and community care teams can be effective, particularly in mental health, but there is limited evidence on cost-effectiveness (eight studies).

What does current guidance say on this issue?

There are no NICE recommendations for delivery of hospital outpatient services, however some NICE guidelines on chronic disease management, such as chronic obstructive pulmonary disease, touch on service delivery arrangements between primary and secondary care.

NHS England’s 2014 Five Year Forward Plan sets out a new direction for the NHS, including how health services need to change and what this will look like. The plan includes improving integration between GPs and hospitals, with more care delivered locally but some services in specialist centres for people with multiple conditions. It also suggests increased joint working between GPs and specialists which can be of substantial educational value.

What are the implications?

This review highlights a number of promising service alterations which may improve the effectiveness of NHS outpatient services. However, evidence is lacking on the cost-effectiveness of greater care provision in the community.

Some studies suggested transferring care to the community may increase the cost of care, with possible reasons including greater demand as a result of new services improving care supply and addressing previously unmet needs.

Evidence suggests transferring care to the community can be justified where considerable importance is placed on patient convenience in relation to NHS costs, or where community care can reduce overall care costs.

This was a broad and high-level review. There may be different emphases and findings relevant to particular clinical specialties or patient groups which cannot be fully analysed here. This review however provides useful pointers around promising interventions and highlights areas where more research is needed.

Citation and Funding

Winpenny E, Miani C, Pitchforth E, et al. Outpatient services and primary care: scoping review, substudies and international comparisons. Health Serv Deliv Res. 2016;4(15).

This project was funded by the National Institute for Health Research Health Services and Delivery Research programme (project number 12/135/02).

Bibliography

NHS England. Five Year Forward View. London: NHS England; 2014.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. CG101. London: National Institute for Health and Care Excellence; 2010.

Roland M, McDonald R, Sibbald B. Outpatient services and primary care: a scoping review of research into strategies for improving outpatient effectiveness and efficiency. Southampton: National Institute for Health Research Trials and Studies Coordinating Centre; 2006.

Winpenny EM, Miani C, Pitchforth E, et al. Improving the effectiveness and efficiency of outpatient services: a scoping review of interventions at the primary-secondary care interface. J Health Serv Res Policy. 2016.

Outpatient services and primary care: scoping review, substudies and international comparisons

Published on 1 May 2016

Winpenny E, Miani C, Pitchforth E, Ball S, Nolte E, King S, Greenhalgh J, Roland M

Health Services and Delivery Research Volume 4 Issue 15 , 2016

Aim This study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B. Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services. Findings from the scoping review Evidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals. Findings from the substudies Because of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS. Conclusions For many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience. Funding The NIHR Health Services and Delivery Research programme.

Expert commentary

This comprehensive health systems research backs up a similar review from 2006 and taps into what many Clinical Commissioning Groups are seeking to do in bringing care closer to home while reducing outpatient department cost.

Of particular interest is the evidence that specialist advice to primary care through e-mail/telephone is safe and effective at reducing this cost. Intensive educational programs top behavioural change but may be costly. Previous evidence of using structured referral sheets/standardisation for GPs is underlined and discharge from outpatient departments to GPs is safe and reduces cost where GPs have adequate support for ongoing care. Many ineffective schemes are of equal interest including feedback on referral rates.

The review highlights the need for robust measurement for outcomes including cost-effectiveness, as while quality often improves, cost savings are too often assumed. The challenge of moving the resource with the patient remains.

Dr Peter Chamberlain, GP and Lead Clinician for Strategy and Innovation, South Sefton Clinical Commissioning Group