This report explores the reconfiguration of clinical services in the NHS and the evidence used to underpin this. As the term reconfiguration suggests, this involves the remodelling or restructuring of clinical services, often between hospital sites, but increasingly between hospital and community settings.
Research aims and objectives
The aims and objectives of this research are to determine:
the current pressures for reconfiguration within the NHS in England and the solutions proposed
the quality of evidence used in making and reviewing the clinical case for change, respectively, any key evidence gaps, and the opportunities to strengthen the clinical case for change.
We have drawn on two key sources of evidence. First, we received the reports produced by the National Clinical Advisory Team (NCAT) documenting its 123 reviews of reconfiguration proposals for the period 2007 to 2012. As we describe later, the NCAT has acted as a key source of clinical advice to those undertaking reconfiguration in the NHS in England. Although the NCAT did not review all reconfiguration proposals in the period, the reviews provide insight into a significant proportion. These reports have been subject to thematic coding and qualitative analysis using NVivo (QSR International, Warrington, UK). Second, we carried out a search and synthesis of the literature to identify the key evidence available to support reconfiguration decisions at specialty level.
Our aim through this analysis is to deepen our understanding of the reconfiguration process and provide new insight into the clinical evidence base used by the NHS and the gaps that exist. The research also provides insight to the NCAT process itself, and the effectiveness of this as a source of clinical assurance to reconfiguration proposals.
Reconfiguration and the evidence to support it
Over the life of the NHS, hospital services have been subject to continued rationalisation and reconfiguration. Yet as Edwards and Harrison1 argued in 1999, research into the running and planning of hospital services has been neglected: ‘it’s rare for the results of hospital reconfiguration to be evaluated’ (p. 1363). As this report demonstrates, little has been done in the intervening period to address this evidence gap.
In any reconfiguration of hospital services there are four interlinked drivers: quality (including safety), workforce, cost and access.2 The challenge for local services is to try to arrive at a configuration that optimises all these elements – as far as this is possible given the complex trade-offs that exist between them. Quality considerations include access to highly trained professionals in all relevant disciplines, compliance with clinical guidelines and access to diagnostic technologies and other support services, as well as strong clinical governance and, for some conditions, the time it takes to access services. There are trade-offs between the quality and financial gains achievable through the concentration of services and the social and clinical costs to the patient of reduced access. There are also interdependencies between services – for example, the withdrawal of paediatric services can threaten obstetric services, which rely on paediatricians to provide care for the newborn child.
The current evidence that can be drawn up to develop a clinical case for change has its limitations. There is good evidence to support centralisation of some services such as trauma and highly specialist surgery based on the volumes of clinical activity needed to secure good outcomes.3,4 However, as we explore further in this report, for many other conditions there is no clear causal link between volume and outcome, and where there is a link, the threshold for quality improvement can be quite low.5 Other factors can be just as important, such as nurse staffing,6 hospital system resources,7 compliance with guidelines and knowledge transfer.
A more compelling and linked driver for the reconfiguration of services in many trusts is their capacity to provide junior and senior medical cover 24/7. Workforce drivers sit behind much of the recently published Royal College guidance on optimal configuration.8–11 Since the application of the European Working Time Directive (EWTD)12 to junior doctors, there has been a 50% increase in the number of junior medical staff required to provide 24/7 care,2 and many units have struggled to achieve this.
There is little evidence to support the notion that the reconfiguration of clinical services will result in significant savings. Posnett argued in 199913 that after a certain critical mass (circa 600 beds), hospitals suffered from diseconomies of scale. Larger hospitals were not always cheaper. Spurgeon et al.3 were unable to reach any definitive conclusion about the financial impact of the reconfigurations they studied, largely owing to the absence of any meaningful financial data. A major review by Goddard of what drives economies of scope and scale in the provision of NHS services [focusing on accident and emergency (A&E) and related services]14 highlighted the ‘dearth’ of economic evaluations. One study of A&E centralisation in Sheffield15 found that the centralised model was more costly. A more recent study of the centralisation of stroke services in London16 was more positive in its findings.
The process of reconfiguration
The 2006 NHS Act17 requires any proposals for ‘significant service change’, such as the reconfiguration of clinical services, to be the subject of public consultation. In 2008, Department of Health guidance said that any proposals to change services should, prior to consultation, be subject to independent clinical and management assessment. This was further strengthened by the Secretary of State in May 2010, who set out that one of his four tests for service reconfiguration was that schemes should demonstrate clarity on the clinical evidence base.18
provides an overview of the reconfiguration process as laid out in 2010.
Overview of reconfiguration process. (J)OSC, (Joint) Overview and Scrutiny Committee; LINks, local involvement networks; OGC, Office of Government Commerce; SHA, Strategic Health Authority; SofS, Secretary of State for Health. Source: David Nicholson, (more...)
shows two potential sources of independent advice and review for local teams taking forward reconfiguration proposals; firstly, a Gateway review from what was the Office of Government Commerce (OGC) and is now Health Gateway Reviews19 (funded and managed by the Department of Health). The Health Gateway Review process provides all NHS and other health public sector organisations with free and confidential independent peer-review support for their projects and programmes. Further details on the Gateway review process are available in Appendix 1.
Secondly, from 2007 to March 2014, a key source of clinical assurance on reconfiguration proposals was the NCAT. The NCAT (funded by a grant from the Department of Health and then NHS England) provided a pool of clinical experts to support, advise and guide the local NHS on local service reconfiguration proposals. The NCAT was also able to provide ongoing clinical advice as individual reconfiguration schemes developed. The role and function of the NCAT is discussed further in Chapter 3.
In December 2013 the guidance was updated to reflect the Health and Social Care Act 201220 and the new NHS commissioning structures.21 This guidance continues to emphasise the importance of clinical engagement and the clinical evidence base: ‘Change must be clinically-led and underpinned by a clear clinical evidence base. It is a key responsibility of senior clinicians leading reconfigurations to construct that evidence base, and to build support within the local clinical community on the case for change’ (p. 8).
The primary source of external clinical advice and support for local teams leading a reconfiguration is now their local ‘Clinical Senate’ who took over the clinical review role from the NCAT in April 2014. Twelve Clinical Senates have been established across England (each covering an area broadly based around major patient flows into specialist or tertiary centres) to be a source of ‘independent, strategic advice and guidance to commissioners and other stakeholders to assist them to make the best decisions about healthcare for the populations they represent’.22 The guidance suggests that this will include:
Providing clinical leadership and credibility. Understanding the reasons why clinical services are achieving current clinical outcomes and advising when there is potential for improvement through significant reconfiguration of services.
Taking a proactive role in promoting and overseeing major service change, for example advising on the complex and challenging issues that may arise from service reconfiguration within their areas.
p. 423
The membership of a Clinical Senate is locally determined. A recent analysis by the Health Service Journal24 showed large acute providers account for 22% of all membership of the 12 Clinical Senates, followed by the local area teams – 12%. Small acute providers make up only 7% and mental health trusts less than 4%. Further details on the membership of Clinical Senates are available in Appendix 1.
Many proposals meet public opposition during the consultation period. The process allows for proposals to be referred by a local Overview and Scrutiny Committee (OSC), convened by the local authority, to the Secretary of State for approval. The Secretary of State may then call on the advice of the Independent Reconfiguration Panel (IRP) when making a decision.
Report structure
The report is structured as follows. In Chapter 2 we describe our methods, including the project timeline and approach. Chapter 3 explores the role of the NCAT and the process of conducting reviews. The main findings from our research and analysis are described in Chapter 4. This chapter is split into a number of sections, one for each significant clinical area. For each key clinical service area we review the relevant NCAT activity, the NCAT’s advice and the evidence base used by the NCAT. We compare and contrast this with the evidence found through our literature search. Chapter 4 also includes an overview of all the NCAT reviews studied as part of this research. In Chapter 5 we discuss our key insights and in Chapter 6 we set out our overarching conclusions and research recommendations.
