Nuffield Trust - "Shifting the balance of care" - March 2017

The Nuffield Trust has published its own research into the credibility of the proposals to shift care into the community, the proposals which underlie Simon Stevens' "Five Year Forward View" (2014) and its implementation in the 44 regional "Sustainability and Transformation Plans" (STPs) (2016).

The Nuffield Trust  "Shifting the balance of care: Great Expectations" was published in March 2017.

I have selected two key messages from the report:

....• Nonetheless, in the context of long-term trends of rising demand, our analysis suggests that the falls in hospital activity projected in many STPs will be extremely difficult to realise. A significant shift in care will require additional supporting facilities in the community, appropriate workforce and strong analytical capacity. These are frequently lacking and rely heavily on additional investment, which is not available.

.....• While out-of-hospital care may be better for patients, it is not likely to be cheaper for the NHS in the short to medium term – and certainly not within the tight timescales under which the STPs are expected to deliver change. The wider problem remains: more patient-centred, efficient and appropriate models of care require more investment than is likely to be possible given the current funding envelope.

From "About the report" (preface):

"This research draws on an extensive literature review to assess the realism of the narrative that moving care out of hospital will save money. It sets the context of this through analysis of hospital activity data over ten years. The literature review focuses on initiatives that were expected to impact on hospital care, as this is what STPs predominantly focus on. We explore these by looking at five key areas: elective care, urgent and emergency care, admission avoidance and easier discharge, at risk populations, and self-care.

The report aims to inform the development of STPs to ensure that they are drawing on the best available evidence. It also seeks to dispel some widely held myths about the ‘magic bullet’ of shifting care into the community."

 

The "Key messages" (executive summary) are:

•" Demographic and other drivers create an imperative to shift the balance of care from hospital to community. The NHS plans to undertake this transition while demand rises and it experiences the longest period of funding constraint in its history.

• There is widespread hope – both within the NHS and amongst national policy-makers – that moving care out of hospital will deliver the ‘triple aim’ of improving population health and the quality of patient care, while reducing costs. This has long been a goal for health policy in England, and is a key element of many of the Sustainability and Transformation Plans(STPs) currently being developed across the country.

• Our analysis suggests that some STPs are targeting up to 30 per centreductions in some areas of hospital activity, including outpatient care, A&E attendances and emergency inpatient care over the next four years. Yet this is being planned in the face of steady growth in all areas of hospital activity – for example a doubling of elective care over the last 30 years.

• The report provides insight from evidence on initiatives that plan to support this shift in care. Drawing on a review of the STPs and an in-depth literature review of 27 initiatives to move care out of hospital, we look at what their impact has been, particularly on cost, and what has contributed to their success or otherwise.

• Many of the initiatives outlined in the report have the potential to improve patient outcomes and experience. Some were able to demonstrate overall
cost savings, but others deliver no net savings and some may increase overall costs.

• Where schemes have been most successful, they have: targeted particular patient populations (such as those in nursing homes or the end of life); improved access to specialist expertise in the community; provided active support to patients including continuity of care; appropriately supported and trained staff; and addressed a gap in services rather than duplicating existing work.

• Nonetheless, in the context of long-term trends of rising demand, our analysis suggests that the falls in hospital activity projected in many STPs will be extremely difficult to realise. A significant shift in care will require additional supporting facilities in the community, appropriate workforce and strong analytical capacity. These are frequently lacking and rely heavily on additional investment, which is not available. [My emphasis]

• We argue that NHS bodies frequently overstate the economic benefits of initiatives intended to shift the balance of care. For example, they may use prices to calculate savings rather than actual costs and can therefore wrongly assume that overhead or fixed costs can be fully taken out. Similarly, many underestimate the potential that communitybased
schemes may have for revealing unmet need and fueling underlying demand.

• The implementation challenges involved in shifting care out of hospital are considerable and even initiatives with great potential can fail. This is often because those responsible for planning and implementing them do not take into account the wide range of system, organisational and individual factors that impact upon their feasibility and effectiveness.
Many schemes rely on models to identify ‘at risk’ groups that are often deficient and fail to adequately identify patients genuinely at risk of increased hospitalisation.

• Many initiatives we examine place additional responsibilities upon primary and community care, at a time when they are struggling with rising vacancies in both medical and nursing staff, and an increasing number of GP practices are closing. Addressing these issues is a necessary precursor to success."

• It is possible that many of the initiatives explored in the report have been too small and haven’t been supported by wider system interventions and incentives, and have therefore failed to shift the balance of care and deliver net savings. A more radical approach to the design and scale of the models being used might be required, but this will take time and resources to support the transition.

• While out-of-hospital care may be better for patients, it is not likely to be cheaper for the NHS in the short to medium term – and certainly not within the tight timescales under which the STPs are expected to deliver change. The wider problem remains: more patient-centred, efficient and appropriate models of care require more investment than is likely to be possible given the current funding envelope. [my emphasis]

 

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