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Headline
The study, drawing on evidence from National Clinical Advisory Team reviews, shows significant pressure to reconfigure services within the NHS in England. The primary drivers are workforce and finance, despite little evidence to suggest reconfiguration will deliver the cost savings anticipated. Many proposals for reconfiguration also fail to be fully implemented because of public and clinical opposition.
Abstract
Background:
Over the life of the NHS, hospital services have been subject to continued reconfiguration. Yet it is rare for the reconfiguration of clinical services to be evaluated, leaving a deficit in the evidence to guide local reconfiguration of services.
Objectives:
The objectives of this research are to determine the current pressures for reconfiguration within the NHS in England and the solutions proposed. We also investigate the quality of evidence used in making the case for change, any key evidence gaps, and the opportunities to strengthen the clinical case for change and how it is made.
Methods:
We have drawn on two key sources of evidence. First, we reviewed the reports produced by the National Clinical Advisory Team (NCAT) documenting its reviews of reconfiguration proposals. An in-depth multilevel qualitative analysis was conducted of 123 NCAT reviews published between 2007 and 2012. Second, we carried out a search and synthesis of the literature to identify the key evidence available to support reconfiguration decisions. The findings from this literature search were integrated with the analysis of the reviews to develop a narrative for each specialty and the process of reconfiguration as a whole.
Results:
The evidence from the NCAT reviews shows significant pressure to reconfigure services within the NHS in England. We found that the majority of reconfiguration proposals are driving an increasing concentration of hospital services, with some accompanying decentralisation and, for some specialist services, the development of supporting clinical networks. The primary drivers of reconfiguration have been workforce (in particular the medical workforce) and finance. Improving outcomes and safety issues have been subsidiary drivers, though many make the link between staffing and clinical safety. Policy has also been a notable driver. Access has been notable by its absence as a driver. Despite significant pressures to reconfigure services, many proposals fail to be implemented owing to public and/or clinical opposition. We found strong evidence that some specialist service reconfiguration including vascular surgery and major trauma can significantly improve clinical outcomes. However, there are notable evidence gaps. The most significant is the absence of evidence that service reconfiguration can deliver significant savings. There is also an absence of evidence about safe staffing models and the interplay between staff numbers, skill mix and outcomes. We found that the advice provided by the NCAT reflects the current evidence, but one of the NCAT’s most valuable contributions has been to encourage greater clinical engagement in service change.
Conclusions:
The NHS is continuing to concentrate many district general hospital services to resolve financial and workforce pressures. However, many proposals are not implemented owing to public opposition. We also found no evidence to suggest that this will deliver the savings anticipated. There is a significant gap in the evidence about safe staffing models and the appropriate balance of junior and senior medical as well as other clinical staff. There is an urgent need to carry out research that will help to fill the current evidence gap. There is also a need to retain some national clinical expertise to work alongside Clinical Senates in supporting local service reconfiguration.
Funding:
The National Institute for Health Research Health Services and Delivery Research programme.
Contents
- Plain English summary
- Scientific summary
- Chapter 1. Introduction and background
- Chapter 2. Methods
- Chapter 3. The role of the National Clinical Advisory Team
- History of the National Clinical Advisory Team
- The National Clinical Advisory Team process
- National Clinical Advisory Team review reports
- National Clinical Advisory Team’s use of supporting external evidence
- Links with other bodies
- Strengths and weaknesses of the National Clinical Advisory Team process
- Strengths
- Weaknesses
- The future of the National Clinical Advisory Team and the provision of clinical assurance to service reconfiguration
- Chapter 4. Main findings
- Introduction
- Section 1: overview of all National Clinical Advisory Team reviews
- Section 2: the National Clinical Advisory Team reviews of a whole trust or health system
- Section 3: accident and emergency, urgent and emergency care (including the reconfiguration of acute medicine and surgery)
- Section 4: elective surgical care
- Section 5: primary and out-of-hospital care
- Section 6: maternity
- Section 7: paediatrics
- Section 8: specialist acute services (including vascular surgery, trauma and stroke)
- Section 9: mental health services
- Chapter 5. Key insights
- Chapter 6. Conclusion and research recommendations
- Acknowledgements
- References
- Appendix 1 National Clinical Advisory Team review process
- Appendix 2 Pro forma for organisations requesting a National Clinical Advisory Team review
- Appendix 3 Information required to inform a National Clinical Advisory Team visit
- Appendix 4 National Clinical Advisory Team reviews: coding framework/structure
- Appendix 5 National Clinical Advisory Team interview topic guide
- Appendix 6 Initial search strings
- Appendix 7 Specialty search strings used to search PubMed
- Appendix 8 National Clinical Advisory Team report template
- Appendix 9 National Clinical Advisory Team guidance on reconfiguration of maternity and children’s services
- Appendix 10 National Clinical Advisory Team reviews summary sheet
- Appendix 11 Project steering group
- Glossary
- List of abbreviations
Article history
The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 12/5001/59. The contractual start date was in October 2012. The final report began editorial review in January 2014 and was accepted for publication in July 2014. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.
Declared competing interests of authors
Nigel Edwards ran a number of learning activities for the Chief Executive Officers of small hospitals.
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