Reconfiguring clinical services: what’s the evidence?

Dr Zoe Wyrko is a Consultant Geriatrician at University Hospital Birmingham and Current British Geriatrics Society Director of Workforce Planning. She tweets @geri_baby. Here she tells us about how the latest King’s Fund paper is relevant to geriatricians.

On Tuesday, the King’s Fund published a new paper called ‘The reconfiguration of clinical services – what is the evidence?’ in which they consider the drivers and evidence base behind the constant push for change which is endemic within the NHS. The authors discuss an analysis carried out by the National Clinical Assessment Team, commissioned by the National Institute for Health Research, and its implications for the National Health Service.

The document confirms what many of us working on the ground have probably suspected for some time: there is no evidence that reconfiguring hospital services on financial grounds alone produces a positive impact, but it does expose organisations to distraction together with clinical and financial risks. There is mixed evidence as to whether reconfiguration with the aim of improving quality is beneficial, with the most positive results found when such changes are carried out related to specialised services. This is clearly highly relevant to us as geriatricians, who are most likely to lead change for this reason.

In keeping with multiple recent reports the authors found evidence that senior medical input is linked with high quality performance, but correctly acknowledge that current workforce issues have an impact on successful implementation of this strategy. Interestingly, they also warn against ‘designing tomorrows services to today’s workforce constraints’  and state that workforce and service planners must work together in order to support development of new models of care.

The authors stress that reorganisation has an important role in delivering quality, but on its own is insufficient, and should be used alongside other measures to “improve delivery of care an organisational culture.”  We should welcome the recognition that there is no one-size-fits-all model to service reconfigurations, and that local context is important. Any plans for reconfiguration must be underpinned by detailed workforce and financial plans, and that following implementation of change there should be routine post-project financial and clinical evaluation.

Chapter 4 specifically considers the reconfiguration of community based services, reflecting the policy direction of delivering ‘care closer to home.’ In summary, the report concludes that it can be hard for community initiatives to significantly reduce hospital admissions, particularly because success in delivering improvement requires systems change  across primary and secondary care, and piecemeal initiatives are ineffective. They also warn that there is little evidence to support the perception that moving care into community based settings will produce financial savings.  Future workforce issues are likely to have significant impact in this area, particularly considering the mismatch between supply and demand  of nurses, who are integral to these types of model. Issues within general practice recruitment are important, with a gradual increase in the number of GPs, but a reduction in participation rates. Despite these negative findings, quality improvements in terms of patient satisfaction and quality of care delivered are emphasised.

Geriatric medicine is also referred to in Chapter 6, which looks at A&E and urgent care services. The report states that “A&E services require …. Rapid access to specialist medical opinion, including geriatricians.” Reasoning given for this statement is to “enable rapid diagnosis and treatment to improve outcomes” which could be interpreted as early Comprehensive Geriatric Assessment, in keeping with published literature and more recently the BGS publication ‘Fit for Frailty.’ Chapter 7, on acute medical services, discusses that there is an urgent need to provide adequate specialist geriatric assessment and support to those aged over 65.

There is no mention of Geriatric support in sections on acute surgery, elective surgery or trauma care, despite these being areas with growing amounts of involvement  from our specialist times. Interestingly, the only area where reconfigurations were driven by ‘Quality’ was Stroke.

This publication could be useful to those who want to drive change, and also those who are having reconfiguration forced upon them. The take home message seems to be that change in a specialist area, driven by experts, with improving quality as the aim can be a success. Warnings need to be heeded when there are other drivers for major change in service structure, and insufficient workforce can result in failure of even the best plans.

Download a .pdf copy of the King’s Fund report here