Tuesday, April 03, 2007

Can Primary Care Reduce OP Demand?

Can primary care reform reduce demand on hospital outpatient departments?

Moving care into the community and closer to people’s homes is very much the mantra of the present government. It is profoundly influencing national thinking and is an important factor in the downsizing and merging of hospitals so that they are serving larger catchment areas. There seems to be a widespread belief held with evangelical zeal in some quarters that treatment in the community clinic, or at the health centre must be in some way superior to care in hospital.

The key question that must be asked is: Where is the evidence? In fact the evidence does not exist so it is refreshing to see that the NHS Service Delivery and Organisation Research Development Programme commissioned research by Professor Martin Roland at the National Primary Care Research and Development Centre at the University of Manchester and he published the results in March 2007 in a paper entitled “Can primary care reform reduce demand on hospital outpatient departments?” The results of this research make essential reading for everybody but especially planners who are thinking of moving more outpatient services into the community. Four different approaches were examined. Transfer of outpatient services to primary care, relocating specialists into community settings, liaison between primary care and specialists and professional behaviour change.

· Transferring Minor Surgery to Primary Care: The Research Findings show little impact on hospital waiting times and some studies show a reduction in the quality of care.

· Transferring Primary Care clinics for chronic conditions: Health outcomes are at least as good in primary care as in hospital outpatients; well-structured GP clinics can reduce outpatient visits while improving access to care. The cost of transferring care in this way is largely unknown.

· Intermediate Care: General Practitioners with Special Interests (GPSIs): Evidence suggests that GPSI clinics provide high quality care with good health outcomes that is more accessible than hospital outpatients and involves shorter waiting times. However, the lack of uniformity in the GPSI model and in arrangements for monitoring GPSI services means that these findings are not robust. The cost of GPSI services varies widely and appears to be generally higher than the cost of specialist services. Some hospital consultants are hostile to the GPSI concept. GPSI services running without local consultant support may be unsafe.

Moving secondary services or specialists to primary care settings: Relocation improves access to specialist care and increases patient satisfaction. With the exception of the attachment of physiotherapists to primary care teams, this strategy has proved ineffective in reducing demand on outpatient services. It has brought no improvement in GP skills or reduction in GP workload. Due to economies of scale, specialists appear to be generally more efficient when working in hospital settings. Relocation may improve equity in care provision in remote rural areas.

Telemedicine consultations between GP and specialist: Liaison models of working may improve the quality of primary care but have little impact on health outcomes. Reduction in outpatient attendances is occasionally, but not consistently achieved. Successful delivery depends heavily on good communication between individual primary and secondary care clinicians.

· Liaison models of working may improve the quality of primary care but have little impact on health outcomes. Reduction in outpatient attendances is occasionally but not consistently achieved. Successful delivery depends heavily on good communication between individual primary and secondary care clinicians.


“A number of potentially effective strategies have been identified that may: reduce outpatient attendance, maintain or improve quality of care, increase convenience for patients. However the evidence does not support some of the assumptions about hospital and community care made within the NHS.”

· Assumption: Care can safely be transferred from specialists to primary care practitioners.
Comment: Not true of minor surgery and not necessarily true of GPSI services.

· Assumption: Care in the community is cheaper than care in hospitals.
Comment: Often not the case. Cost evaluation should not focus purely on NHS costs but also on prices charged by providers.

· Assumption: Transferring care into the community will not increase overall demand.
Comment: There is a serious risk that increasing provision may increase demand either because of increased demand from patients or increased referral from GPs.

· Assumption: Care in the community is popular with patients and should be encouraged.
Comment: The general popularity of this policy would not necessarily survive loss of quality and efficiency.

Commentary from City Hospital Supporters:

This is an important piece of work commissioned by the NHS and performed by the National Primary Care Research and Development Centre, an organisation impeccably qualified to objectively investigate moving work done in secondary care to the primary care sector. City Hospital Supporters congratulate Professor Roland. This work does not support the wholesale move of secondary care outpatient services to primary care. There are serious reservations and uncertainties concerning the quality of care and cost.It is to be hoped that the Sandwell and West Birmingham Hospitals NHS Trust, the Heart of Birmingham Primary Care Trust and the Sandwell Primary Care Trust take note of this work. We are providing them with copies of the paper. Their Towards 2010 plan envisages moving a lot of the hospital services into the community. This would include a lot of work currently being seen in the A&E Department at City and Sandwell Hospitals. This subject was not covered in Professor Roland’s paper but presumably these bodies will be providing published evidence that such changes are justified? However this may prove difficult as City Hospital Supporters do not believe this work has been done. Doctors are quite rightly not permitted to treat patients with untried and untested medicines, so why are government and health care organisations permitted to introduce untried, untested and unproven schemes that could prove excessively expensive to taxpayers and provide less efficient and poorer quality health care?

The original full paper is available here.



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