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.
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).
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.
Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre