Ed Martin Roland, Jonathan Shapiro
Radcliffe Medical Press, £15, pp 120
ISBN 1 85775 218 X
Specialist outreach clinics in general practice are not new, but their numbers have increased substantially since the introduction of general practitioner fundholding. Their character has probably altered also. Earlier schemes largely followed the “liaison-attachment” model, aimed at improving patient care through collaboration between general practitioners and specialists.
Recent schemes mostly follow the “shifted outpatient” model: the location of care moves from hospital to the general practice surgery, but otherwise it remains unchanged. Most have been motivated by fundholders’ desire to improve access to outpatient services and to reduce the time and costs of waiting and travelling for their patients. The scope for this is considerable. Cumulatively, the 200 000 outpatients who annually attend a typical district general hospital spend an estimated lifetime (just over 67 years) travelling and waiting to be seen.
The five case studies of outreach clinics described in this book substantially increase our understanding of their operation, but the evidence remains fragmentary and often contradictory. Their results are broadly consistent: outreach clinics are associated with increased satisfaction among patients (who value the convenience and familiarity of the setting and the continuity and seniority of care) and reduced time and costs of travel for patients. However, they probably increase NHS costs overall, because of staffing of outreach clinics by consultants only and the time and costs of travel that they incur for the consultants. There were also less quantifiable “system” costs (such as the impact on supervision and training of junior hospital staff). Whether these additional costs were offset by gains in effectiveness and quality of care remains unknown because comparisons of clinical outcomes (discharges, admissions, investigations) with outpatient clinics are confounded by differences in case mix and levels of staffing between the two settings. As presently constituted, they would probably not be cost effective on a large scale.
Although fundholding is passing, key issues raised by outreach clinics remain. When reconfiguring services, how do we balance responsiveness to local needs against the drive to increase the cost effectiveness of the system overall? In the new NHS, how (and how far) do we take patient preferences into account or incorporate their costs into economic appraisals of services? The internal market contained few mechanisms for reconciling local benefits and system costs and no incentive for anyone to try. Joint commissioning and funding could do, but they do not guarantee a solution. Anyone looking for clear and level headed guidance on outreach clinics or struggling to develop services across traditional sector boundaries will find help here.
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Rating: ★★★