Moving specialist care into the community: an initial evaluation.
OBJECTIVE
To assess the likely impact on patients and local health economies of shifting specialist care from hospitals to the community in 30 demonstration sites in England.


METHODS
The evaluation comprised: interviews with service providers at 30 sites, supplemented by interviews with commissioners, GPs and hospital doctors at 12 sites; economic case studies in six sites; and patient surveys at 30 sites plus at nine conventional outpatient services. Outcomes comprised: staff views of service organization and development, impact on primary and secondary care, and benefits for patients; cost per consultation and cost per patient in new services compared to estimates of the price of services if undertaken by hospitals; patients' views of waiting time, access, quality (technical and interpersonal), coordination and satisfaction.


RESULTS
New services required high initial investment in staff, premises and equipment, and the support of hospital consultants. Most new services were added to existing hospital services so expanded capacity. Patient reported waiting times (6.7 versus 10.1 weeks; p = 0.001); technical quality of care (96.2 versus 94.5; p < 0.001), overall satisfaction (88.2 versus 85.4; p = 0.04); and access (72.2 versus 65.8; p = 0.001) were significantly better for new compared to conventional services but there was no significant difference in coordination or interpersonal quality of care. Some service providers expressed concerns about service quality. New services dealt with less complex conditions and undercut the price tariff applied to hospitals thus providing a cost saving to commissioners. There was some concern that expansion of new services might destabilize hospitals.


CONCLUSIONS
Moving specialist care into the community can improve patient access, particularly when new services are added to existing hospital services. Wider impacts on health care quality, capacity and cost merit closer scrutiny before rollout.
Sibbald
Bonnie
B
National Primary Care Research and Development Centre, University of Manchester, Manchester, UK. bonnie.sibbald@manchester.ac.uk
Pickard
Susan
S
McLeod
Hugh
H
Reeves
David
D
Mead
Nicola
N
Gemmell
Islay
I
Coast
Joanna
J
Roland
Martin
M
Leese
Brenda
B
D006801:Humans; D007407:Interviews as Topic; D008511:Medicine; D009936:Organizational Innovation; D011320:Primary Health Care; D011365:Professional Practice Location; D015397:Program Evaluation; D013038:Specialization; D011795:Surveys and Questionnaires