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Shifting care out of hospitals unlikely to save NHS money, in most cases

Rising demand and under-resourced transition will scupper that hope, says report

Caroline White

Wednesday, 01 March 2017

Shifting care out of hospitals into the community can deliver holistic, patient-centred care closer to home. But in most cases it is unlikely to save money, finds a report* published today by The Nuffield Trust.

Moving the locus of care is a key tenet of Sustainability and Transformation Plans (STPs). But rising patient demand and the lack of adequate resource to finance the transition will scupper that hope, in most cases, says the report.

While there is general consensus that care closer to home is often better for patients, doubts are beginning to surface about the feasibility of the plans to save money, says the Nuffield Trust, highlighting last week’s report from health think tank, The King’s Fund, which concluded that the STPs were not credible without extra investment to stabilise the NHS and social care.

The report is based on a review of 27 schemes to reduce hospital activity, which included changes to urgent and emergency care pathways; speeding up discharge; managing ‘at risk’ groups; supported care at home; and cutting down on admissions.

Most of the initiative had the potential to improve patient experience, and in some cases, outcomes.

But the evidence on cost savings was much less clear cut, partly because good economic evaluations have often not been carried out.

A few schemes did seem to be cost-effective in the right circumstances — where GPs can access specialist advice via email or other means, this is associated with a reduction in outpatient referrals and more timely access to treatment, for example.

But where schemes had been evaluated, most were cost neutral or were more expensive. 

“To get them right many are resource intensive or place unrealistic burden on other parts of the system. In particular, many of the schemes we reviewed require those in general practice to take on new responsibilities or to work in ways they are not used to. This is a big ask when general practice is already stretched to the limit,” says Sophie Castle-Clarke, fellow in health policy at the Nuffield Trust.

“If general practice is going to take on more, it will require more resource – not only for additional personnel but also for improved infrastructure, additional training and greater collaboration with specialist and community services. In some cases, revised payment structures and incentives are also likely to be required to formally reflect the shift in responsibilities from secondary to primary care,” she adds. The same is true of social care: a cash injection is required.

A survey of 63 healthcare leaders, commissioned for the report, shows that the primary obstacle in the way of an effective transition is lack of adequate funding, cited by 40%of respondents, closely followed by the system of incentives and payments, cited by nearly a third.

“Moving care out of hospitals can deliver holistic, patient-centred care closer to home, improving patient experience. But in most cases it is unlikely to deliver savings. In the context of growing activity, and an absence of additional resource to support transformation, the long-standing ambition to shift the balance of care from hospital to community may still prove to be elusive,” concludes Castle-Clarke.

Niall Dickson, Chief Executive of the NHS Confederation, commented: “This is a timely report which shows how NHS organisations and their local partners are driving change to bring care closer to people’s homes.

“There are many encouraging signs from a host of schemes around the country but it is right to point out that care in the community is not always or necessarily cheaper and that it does require extra resources - including properly trained staff to deliver these new ways of delivering care.”

He added: “The NHS is facing an unprecedented double whammy – manage the pressures while transforming the care. That is a big ask and there is a very real risk that the demand to cut budgets and meet ever rising demand will derail these plans.”

* Imison C, Curry N, Holder H, et al. Shifting the balance of care: great expectations. Research report March 2017. Nuffield Trust.

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