Title: Outpatient services and primary care: scoping review case studies and international comparisons
Funder: Department of Health (England)

Abstract: This application has been prepared at the invitation of Health Services and Delivery Research (HS&DR) to update an SDO funded review of outpatient services published in 2007 (www.netscc.ac.uk/hsdr/projdetails.php?ref=08-1518-082). The aims of this updated review are similar to those of our previous study namely to:1. Identify and review what is currently known about strategies involving primary care that are designed to improve the effectiveness and efficiency of outpatient services.2. Comment on the impact of such schemes on the organisation of primary care on the primary care workforce on access clinical outcomes for patients and on patient experience.3. Identify and comment on the potential for innovative models of care to be replicated more widely.4. Identify the needs for future research in this area both in terms of primary research and systematic reviews that might be needed.5. Summarise the findings in a way that will be readily accessible to policy-makers and managers.We propose to extend the work beyond the previous literature review to include a number of case studies of new developments have occurred especially around demand management which will be of increasing importance in future years but are not yet adequately represented in the published literature. We also believe that there are opportunities to learn from the approaches and experience of other countries. Our proposal therefore describes three areas of work: literature review case studies and international comparisons.1. Literature review.The scoping review of the literature (see full protocol for definition of scoping review and description of the methods) will follow the format of the previous review with some changes. We will now include the following headings: (i) Transfer (substitution of primary care for secondary care) - Surgical clinics (e.g. minor surgery) Medical clinics (e.g. diabetes asthma) intermediate care (e.g. GPs with special interests) outpatient discharge to primary care direct access of primary care provider to secondary care for diagnostic tests/ investigations / services.(ii) Relocation (relocation of secondary care to primary care settings -the provider remains a specialist) - shifted outpatient clinics telemedicine and telecare (see definitions in full proposal) attachment of specialists to primary care teams community mental health teams(iii) Liaison (joint management of patients by primary and secondary care clinicians) Shared care (joint management plans) consultation-liaison (joint consultations and management plans).(iv) Professional behaviour change (interventions intended to reduce rates of referral) - guidelines audit and feedback academic detailing professional education in-house referral (i.e. second opinion) referral management centres financial incentives(v) Patient behaviour change (Decision aids and aids to patient choice designed to influence decisions about referral to and discharge from specialist clinics)(vi) Hospital service redesign e.g. rapid-access clinics hospital outreach services that bypass primary care.Identified data sources will be documented and each set of findings will be summarised under five headings: access including waiting times clinical outcomes for patients patient experience service outcomes and cost.2. Case studies.To augment the scoping review of the literature we propose a number of case studies of interventions which we believe are inadequately described in the literature and may be of increasing importance in the NHS in future years. These are:(i) Referral management centres(ii) In-house review of referrals(iii) Financial incentives to reduce referral(iv) Consultants contracted to work for primary care organisationsThe first three of these have in common that they are driven by an explicit aim to reduce the number of outpatient referrals. In this respect they contrast with other interventions which focus on other aims including convenience for patients up-skilling of GPs more cost-effective provision of services etc. We believe that this type of intervention will become more common in the NHS as a result of the continued pressure on budgets. Through these case studies we aim to describe a range of interventions which have been used to reduce or limit the rise in outpatient referrals and to describe the potential positive and negative effects of the schemes on clinical practice and to describe the potential effectiveness of the schemesIt is important to note that the methods proposed are not intended to measure the effectiveness of schemes though we will define a broad range of likely outcomes and articulate the questions that need to be addressed in future research on the cost-effectiveness of such schemes.The fourth change which again is not currently described in the literature is a change in the employment arrangements for consultants in particular consultants who are either fully employed by primary care organisations or who have joint contracts between acute trusts and primary care organisations. We will select specialties which have traditionally been seen as hospital specialities which are of particular interest because they straddle a boundary between organisations with competing priorities – i.e. commissioners and providers. We will to include a fourth set of case studies in this area. Again the methodology proposed is not intended to measure the effectiveness of such contracts but will define a broad range of issues that need to be addressed in future research which might more formally evaluate consultants working in non-traditional roles and settings.3. International experienceFinally we will examine experiences in a set of OECD countries of innovative approaches and models of care designed to enhance the effectiveness of services at the primary-secondary care interface. This component principally draws on our expertise built within an ongoing project that provides comparative information and intelligence on healthcare policies in a range of European and other high income countries for the Department of Health in England using an established network of expert informants.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE