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Care closer to home

BMA briefing and position statement (England only)
October 2007

The BMA supports care being delivered ‘closer to home’ where it is clinically appropriate and safe to do so, where sound evidence supports such a shift and where these new services will genuinely offer a cost-effective option. Proposals and communications from the Department of Health however often appear to oversimplify ‘care closer to home’ both in terms of its inherent value and the practicalities involved. For example, just because care is delivered closer to home, this does not automatically make that care better or more patient-centred. Similarly, the length of a patient’s stay in the acute setting cannot be used as a measure of quality of care per se; a longer stay does not necessarily indicate worse care.

We have monitored the progress of the Department of Health’s Care Closer to Home Demonstration Group, (Footnote (1) - go there now) which has recently released a commissioned, evaluation report (Footnote (2) - go there now) looking at thirty selected pilot sites across six specialties – ear, nose and throat; orthopaedics; dermatology; urology; gynaecology and general surgery – where elements of care had been shifted into community settings. Given the short timescales involved, the evaluation report was unable to provide definitive information about efficiency, effectiveness and costs. Nonetheless, it has drawn out some very important insights as well as raising some critical questions that cannot be ignored. A second report has also been published, written by members of the demonstration group, which seeks to provide doctors with more a practical guide to implementing ‘care closer to home’ in each of the six specialties listed above.

There is a relatively small, but growing number of excellent examples of clinical innovation across the country that could be defined as ‘care closer to home’. Such innovations have developed bottom up, in response to specific local circumstances and usually driven by individual enthusiasts with specific skills and/or qualifications. We advise caution in assuming that it would necessarily be helpful to patients to draw general conclusions from such examples: models of service provision in one part of the country may well not add value in another setting. Furthermore, these service innovations are most successful when they are the product of good local relationships as ultimately, what is best for patients should be decided by the consensus of local clinicians, ideally from both primary and secondary care, in cooperation with informed patient views. There is little point in imposing a service that patients do not wish to choose.

There are a number of GPs, some through their involvement in practice based commissioning (PBC), who have very positive plans and ambitions for the development of services ‘closer to home’. There are of course a number of practical problems being faced by clinicians attempting to put such plans into practice, for example start-up costs for new services will be significant and, at present, the source of associated funding is unclear. However, a more pertinent point to note is the evaluation report’s observation that ‘…high quality, safe and effective services are much more likely to develop in areas where there is close working and mutual support between primary and secondary care staff.’

The BMA supports better working between primary and secondary care, which we feel is undermined by the adversarial culture that is being fostered as a result of recent trends in NHS reform. If the government wishes to see widespread and successful implementation of ‘care closer to home’ led by NHS providers, then it will need to pay particular attention to the issue of the right environment and recognise the influence that national policy has had on clinicians’ relationships at a local level.

The BMA welcomes 'care closer to home' initiatives that adhere to the following principles:

• The service is clinically appropriate and safe;
• Development of the service is patient-centred;
• There is evidence to support development of a new service, or at the very least, clinicians’ consensus that this is an appropriate shift;
• The service will be cost-effective, represents value for money and best use of NHS funding;
• The service maintains or improves upon existing quality standards;
• The service maintains continuity of care, especially for patients with long-term conditions;
• Proposals to shift ‘care closer to home’ should include a full, advance assessment of the impact of such a move (if any) upon local primary and secondary care facilities and existing services, including mitigation of unintended consequences;
• Existing and future training needs have been taken into account;
• Improving patient access and/or convenience should not be at the expense of quality, excessive costs or worsened health inequalities;
• The ‘care closer to home’ service is established before the transfer of the patients and their care to a community setting;
• All such shifts of care should be fully costed and resourced and not, for example, be assumed to be an extension of general practice ‘essential services’;
• The service promotes an integrated approach, with collaboration between clinicians in primary and secondary care.

Footnote (1) - For more information on the project and to access the two reports - please click here.
Footnote (2) - This work was commissioned from the National Primary Care Research and Development Centre.