Providing care closer to home
Authors: Chris Salisbury, Sarah Purdy
Journal: BMJ (2007)

The 2006 National Health Service (NHS) white paper, Our health, our care, our say, set out a strategy to provide more services in the community, closer to people's homes.1 The report of the evaluation has just been published,2 along with a report from the specialties involved.3 The strategy was based on international experience that moving care from large hospitals to smaller local sites improves patient satisfaction and outcomes and is more cost effective. The scheme involves new and more integrated care pathways, polyclinics that provide a wide range of diagnostic and therapeutic services,4 and renewed investment in community hospitals. Plurality of services, and the system of “payment by results” by which money follows patients, should enhance patient choice and incentivise quality and value.5

The white paper included a commitment to evaluate the strategy in 30 “closer to home” demonstration sites in six specialties: dermatology; ear, nose, and throat; general surgery; gynaecology; orthopaedics; and urology. The services provided by the demonstration sites varied, from home based catheter care to day case surgery. Many involved general practitioners, nurses, or other health professionals working as practitioners with special interests. Implementation of the demonstration sites and their effect on access to care, quality of care, and costs were evaluated.

What can we learn from these reports? Developments were often driven by the enthusiasm of local clinicians and the availability of a suitable venue, as much as by healthcare needs. Not surprisingly, sites that had local champions and that consulted widely with stakeholders found it easiest to establish services. Some sites creatively redesigned services to break down traditional barriers between primary and secondary care. The aim of improving patient satisfaction appears to have been achieved. Patients found the new local services more convenient, they experienced shorter waiting times, and they were happy with the quality of care they received.

Drawing conclusions about cost effectiveness is more problematic. Under payment by results, hospitals are paid using a fixed national tariff, which is based on an estimate of the average cost of providing care within broad categories such as general surgery outpatients.6 A standard tariff was used to encourage providers to focus on quality and quantity of referrals rather than price.5 However, many of the demonstration sites provided care for simple procedures at well below the tariff. This does not mean that these demonstration sites necessarily represent better value, as it is important to distinguish between the cost of providing a service and the price hospitals have to charge. Several studies have shown that care in the community is generally more costly than hospital based care.7 8 9 Diverting low cost cases, on which hospitals make a profit, while leaving them with the complex and expensive cases, on which they make a loss, is unsustainable.

In addition, most demonstration sites were designed to increase capacity so that waiting lists could be cut; this represents an additional cost. Savings can be made only by disinvesting in hospitals, but if the marginal cost of providing low complexity care in hospitals is less than the cost of establishing new services in the community this may not ultimately be good value. Finally, the increased capacity, accessibility, and popularity of closer to home services are likely to lead to an increase in demand, particularly if (as in some cases) these services provide direct access for patients without referral from a general practitioner. Therefore, this policy could actually increase total costs to the NHS.

The third aim of the policy was to improve outcomes for people. Although the evaluators asked patients and staff about quality of care, no objective measures of quality, outcome, or competency were available. This is worrying, as care is being transferred from one type of practitioner to another and from centralised units to smaller peripheral centres. Both hospital consultants and some of the community practitioners expressed concern about this matter. In particular, some nurses were worried about their lack of training for the new responsibilities they had been given. Training needs and accreditation criteria have now been defined for general practitioners and pharmacists,10 but for nurses this is an ongoing problem that needs to be resolved, and robust arrangements to audit quality and outcomes are essential.

Finally, a tension exists between promoting patient choice and providing value for money. The demonstration sites seemed to be designed to increase choice for commissioners rather than for patients, because they often involved triage of patients referred for secondary care. Some patients prefer to attend hospitals,11 and it will be interesting to see whether commissioners allow this choice to be exercised if the price of hospital care is higher.

Despite these caveats, the aim of providing care closer to home is laudable. It could potentially offer high quality and accessible care in a way that patients prefer. The vision set out in the white paper is radical and could have important implications for the future shape of health care in England. However, most of the demonstration sites are currently of small scale, and the evaluation provides limited evidence about the costs and benefits of the policy. It highlights the need for careful attention to implementation, costs, quality, and training as the policy is rolled out more widely.