The future for specialists is beyond a hospital’s four walls

In Simon Stevens’ vision for the NHS, by 2020 it will be commonplace to see hospital consultants working closely with their primary and community care colleagues in new integrated systems.

‘When working outside hospital, specialists can become educators that enhance the skills of GPs’

When a patient is ill, instead of going to their local GP surgery, patients would be seen by a range of health and social care professionals in what he calls “multispecialty community providers” based around general practices or “primary and acute care systems” run by hospitals.

Today, in most – although by no means all – specialties, hospital consultants rarely work outside hospital. This is despite an increasing number of patients with complex needs who could be treated closer to their homes if the support, expertise and resources were available to do so.

• Bewick: Up-skilled GPs should support emergency and acute services
• Are US style ‘hospitalists’ the answer for 24/7 working?
• ‘New care models’ to cover half of England

Four key themes

The King’s Fund recently visited six services in which innovative hospital consultants have started to work outside hospital to address this problem. We identified four common themes that are key to these new ways of working.

First, when working outside hospital, specialists can become educators that enhance the skills of GPs and other healthcare professionals. As well as actually treating patients, they provide support and training to help GPs and nurses diagnose and treat more complex patients themselves. Examples of this include:

• Email and telephone helplines that GPs, nurses and other healthcare staff can use to discuss patients with specialists before they are referred to hospital.
• Specialist participation in multidisciplinary team meetings to discuss patients with primary, community and social care colleagues.
• Specialist run education sessions such as one to one sessions for GP practices on topics of their choice or clinical commissioning group-wide training events in treatment and diagnosis skills.

Specialists’ strategic role

Second, some successful examples take a care pathway approach to service redesign. This includes specialists taking on a strategic role in planning services that address patient needs at each stage of their journey from home to hospital.

Geriatricians in Leeds have done this with their interface geriatrician service, where a range of services in the community and hospital have been developed to help keep patients out of hospital.

The geriatrics team at Leeds Teaching Hospitals Trust work with their local community trust. Innovative features include:

• Geriatricians assessing patients in accident and emergency to avoid unnecessary hospital admissions.
• A Patient Care Access Line through which GPs and community services can get patients directly admitted to hospital beds or get advice to help avoid admissions.
• Input into multidisciplinary meetings – working with social workers, district nurses and others to proactively manage patients to help them stay at home.

Isolating the impact of the interface geriatrician service is difficult. However, since its introduction, the rate of growth in emergency admissions for older people in Leeds has declined from 5.9 per cent a year in 2012 to 1.7 per cent in 2013.

During the first year that geriatricians assessed patients in A&E, 60 per cent were discharged, compared to a usual discharge rate for those aged 75 and over of between 20 and 33 per cent.

Population approach

Other sites took this a step further and designed out of hospital services that take a whole patient population approach. This means designing initiatives that seek out undiagnosed patients, educate the public about prevention and help people better manage their chronic conditions at home.

‘Before making changes to the structure of the workforce, it is necessary to clearly redesign the nature of the work outside hospital’

The Imperial Colleage Healthcare Trust child health GP hubs provide a great example of this – they are recruiting practice champions in local GP surgeries who provide a link between local communities and health services. Young people, parents and carers are co-designing initiatives such as peer-to-peer support to help the local community stay healthy.

A third theme was the need to develop the workforce outside hospital, with new roles for specialists and the wider workforce. Consultants can have integrated roles that span primary and secondary care settings, but for this to be successful, their time needs to be ringfenced to protect it from commitments on the wards.

The Whittington respiratory service (see video, below) has done this with its integrated respiratory consultant role: two hospital consultants have time carved out in their contracts to lead the community diabetes team and coordinate respiratory services across hospital and the community.

Extended roles

These new ways of working can also involve new roles for nurses and other allied health professionals. Consultants can enable this through training and supporting others to work in new and extended roles.

The Haywood Rheumatology Centre has developed new roles, including a consultant in community rheumatology and consultant physiotherapist, to treat patients in its musculoskeletal service located in a community hospital.

The final theme that we found throughout the case studies was that before making any changes to the structure of the workforce, it is necessary to clearly redesign the nature of the work outside hospital to avoid duplication.

A great example of this is the Portsmouth and South Eastern Hampshire diabetes service, where they have clearly defined the patients who will be seen in primary care and those seen in hospital.

In Portsmouth and the surrounding area, consultants, community and primary care staff defined a “super six” list of patient groups whose diabetes must be managed in hospital.

The care of all other patients with diabetes was discharged to primary care. A community diabetes team of hospital consultants and specialist nurses help GPs and practice nurses treat these patients by:

• providing a telephone and email service for specialist advice;
• conducting biannual consultant visits to practices to discuss practice diabetes work;
• running a comprehensive multidisciplinary diabetes care education programme, free for local health professionals; and
• delivering DESMOND education programmes.

These services were established by strong clinical leaders, who were prepared to work outside their usual professional boundaries and put in time – often unfunded – to develop relationships across their local area and persuade others to work in new ways.

‘Resources will be needed to allow GPs and nurses to take on extended roles and take advantage of training opportunities’

Sometimes a decade or more had been spent developing relationships and piloting approaches.

But how can this type of service change be implemented in an area that does not benefit from that history? One clinician told us that putting the patient voice at the centre of service redesign made the most compelling case for change.

Strong partnerships

Although clinicians led these service developments, successful implementation requires strong partnerships with commissioners. CCGs can adapt models for wider roll-out and, by working in partnership with academics, ensure evaluations are an integral part of the service design right from the outset.

‘We saw great potential in consultants becoming part of multidisciplinary teams with strategic responsibility for planning services’

To enable change, transformation funding will be needed – to fund development activity and allow for possible initial double running of services while new approaches are piloted.

A major barrier to implementing these new ways of working is workforce capacity. Hospital consultants are working to deliver cover in hospital seven days a week, and ringfencing time for out of hospital work is difficult.

There are also major implications for primary and community care staff, who are already straining under the pressure of rising patient demand. Resources will be needed to allow GPs, nurses and others to take on extended roles and take advantage of education and training opportunities.

These services may uncover unmet demand from patients who were not previously receiving treatment. For example, the Sunderland dermatology service provides treatments in a primary care centre that are also available in hospital.

They had expanded from treating 5,000 patients to 12,000 within the same funding envelope. At the same time, referrals to the local hospital service have not decreased. This suggests out of hospital initiatives must be of sufficient scale to allow other services, for example, a hospital clinic, to be closed in response without affecting patient care. 

Placements for trainees

The focus of these models is on developing the current workforce. However, to have long term durability, they must include placements for trainees to develop future clinical leaders who are accustomed to working across organisational boundaries.

We saw great potential in consultants becoming part of multidisciplinary teams outside hospital – working as educators across hospital and community settings, with strategic responsibility for planning services, and acting as change champions who persuade staff to work in new ways.

There are also clear challenges to implementing these new ways of working when the hospital, community and primary care workforces are under pressure and NHS finances are constrained.

Although these approaches are unlikely to generate huge cost savings, they can provide better quality, more coordinated care for patients.

Hospitals need to start thinking now about how they will work with commissioners, primary, community and academic colleagues to make these innovative models of care part of the NHS’s future.

Ruth Robertson is a fellow and Matthew Honeyman is a research assistant at the King’s Fund