This report examines and updates the review of evidence of underpinning the policy drive to transfer acute inpatient and day-case services from hospitals into the community and the effectiveness of this to improve quality of care and save money.
All health services are facing up to the enormous challenge of delivering better care whilst simultaneously reducing costs with a reoccurring claim that to tackle this care needs to be moved out of hospital and into primary and community settings. It is argued that by moving care out of expensive hospitals and closer to patients homes not only can cost savings be made but other aspects of quality of care can be also be improved. Despite such a compelling narrative and more than decade of policy directed towards encouraging this shift, it is remarkable what little progress has been made on the ground.
The Health Foundation therefore commissioned this review of the evidence to explore the extent to which it is know whether this is an effective policy and if so where efforts to shift care should be focused.
What are our findings?
The evidence does show that community-based services can, under the right conditions, provide quality of care that is as good as that in hospital and, in some instances, at a lower cost. Findings on patient satisfaction are less equivocal; ease of access, travel and shorter waiting times are typically cited as improvements when care is closer to home.
The review also identified that there is particular potential for community-based services to help reduce NHS costs by promoting early discharge from hospital for patients who no longer need intensive acute care, but are not yet ready to fend for themselves at home. However, for significant cost savings to be realised moving care into the community needs to be associated with active reductions or decommissioning of hospital-based services.
The conclusions are appropriately cautious, however. The majority of the published evidence fails to contain robust cost information on infrastructure, planning and start-up costs. Furthermore, much of the evidence is based on small, highly [patient] selective pilots making it difficult to make system-wide generalisations for a broader range of patients.
What is the Health Foundation doing?
The Health Foundation is supporting research into value for money in healthcare, which is building the evidence base to inform how changes in health service delivery can be made to help address the challenge of continuing to improve quality for patients in a demanding financial climate, including our work on whether better clinical coordination improves quality and saves money and whether quality improvements in primary care reduce secondary care costs.
We are currently working with leading academics on other value for money research projects including macro level health economics analysis, examination of the comparative value of components of care pathways and the extent to which patient collaboration can increase value for money in healthcare services.
Who should read this report?
This report will be of interest to decision-makers and commissioners of health services or those involved in the rethinking of traditional patterns of where and how care is delivered and its implementation. The onus on these groups, going forward, will be to demonstrate that an evidence-based clinical voice can deliver the panacea of service reorientation that previous incarnations of commissioning have found so difficult to achieve.