Introduction
Chapter 1 discussed the importance of a whole-system approach to hospitals.
Health care analysts and professionals increasingly accept the notion that ‘the hospital’ is only one, albeit important, link in a complex continuum in which patients move between different levels and types of care. As a result, increasing attention is paid to the concept of the interface: how and where different levels of care intersect and where patients move from one mode of care to another.
In the context of the hospital, this attention has focused on the interface between primary and secondary care and between hospital and post-hospital care. Hospitals have multiple functions and therefore a large number of possible interfaces. For example, hospitals concentrate professionals and technology in a single location to deliver specialized patient care; hospitals may serve as organizational hubs, providing a focal point for care providers based outside the hospital; hospitals also educate and train local health care professionals.
The concept of interface has two parts. First, any of the interfaces represent frontiers or boundaries between care providers. As a frontier, the interface may provide an opportunity for the hospital to filter patients and to mediate de-mand that is considered inappropriate (or that cannot be met). The interface as boundary provides the opportunity to insert physical or process filters (for example, referral systems for non-urgent care and medical assessment units in emergency rooms) that can turn back or re-route patients who do not require acute care. The boundaries may be:
chapter
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Organizational: responsibility for the care of the patient shifts between organizations, for example, from the general practitioner to hospital.•
Physical: the patient has to leave home to be admitted to hospital.•
Financial: a different payer or mode of payment may be used for primary and inpatient care.The second property of the interface is that it comprises a set of interactions, flows and mechanisms by which patients can move from one level of care to another: a bridge across care boundaries. At the core of this notion is the flow of information (in all its forms), on which the smooth and appropriate transi-tion across care boundaries depends. Arguably, changes in both modes of information transfer and attitudes to communication and coordination are at the heart of changing attitudes towards interfaces between hospital and non-hospital care. Clearly, developments in communications technology continue to make information transfers technically easier and cheaper, but more import-ant than the hardware of communication has been a shift in the expectations of health professionals as to what constitutes minimally acceptable levels of communication and coordination. The culture of protocol-driven care makes professionals engage with one another more closely, while simultaneously formalizing information flow requirements at various stages of care.
This chapter uses the experience of the United Kingdom to illustrate some of the issues that face health systems across Europe. During the 1980s, the National Health Service (NHS) in the United Kingdom had been at the forefront of efforts to shift the balance of care between hospitals and primary care and gained extensive experience with a wide range of different policies. We explore some of the key changes that have marked the recent evolution of information flows across care interfaces, with reference to a stylized model of the relation-ship between general practitioners and hospital-based specialists. We also offer a critique of models in the United Kingdom where this is appropriate.
Approaches to improving the operation of hospital interfaces with the outside world revolve around three fundamental strategies:
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improving the coordination of care;•
shifting organizational and care boundaries; and•
bypassing or substituting for hospital or inpatient care.The inward interface: preventing admission and bypassing hospital
The inward interface has frontier and boundary points at which patients can be diverted, filtered and channelled. Figure 5.1 presents a stylized representa-tion of the key interfaces between patients being admitted to hospital and types of secondary hospital care.
The hospital as a provider of ambulatory care
Ambulatory care includes outpatients, minor accident cases and day treatment, including surgery, endoscopy and other investigations. This represents the
Figure 5.1 Inward hospital interface links
largest single activity of most hospital services in the United Kingdom and most other health systems. As previously noted, despite the very large volume of care provided, there is surprisingly little research into the function, organ-ization or management of ambulatory care.
Overall outpatient activity in the United Kingdom has risen relatively slowly and consistently in recent years. In 1979, there were 28.425 million outpati-ent attendances across all acute specialties in England; this rose by an average of 1.2 per cent annually to 36.057 million attendances in the fiscal year 1996–
97 (Department of Health 1997). This slowly expanding outpatient workload has been spread across a growing number of consultant specialists so that the number of outpatient attendances per consultant has declined steadily (Armstrong and Nicoll 1995).
Systems that allow patients direct access to specialists, as in France, Ger-many, Sweden and the United States, tend to have higher costs than those that insist on general practitioner referrals, such as Denmark, Finland, the Nether-lands and the United Kingdom. The absence of both an agency mechanism and a filter and interpreter of information directly affects hospital activity (Starfield 1994). Furthermore, systems that link in some way to the referring physicians’ remuneration are more effective at reducing referrals and encour-aging alternative ambulatory care. These include systems that require a referral from primary care to hospital fee-for-service systems, or include fundholding,
GP= general practitioner
or where hospital treatment is covered by a capitated allowance. Having said this, the introduction of general practitioner fundholding in the United King-dom seemed only to slow growth in referrals from capitated fundholders relative to non-fundholders and not to actually reduce referral rates (Surender et al. 1995). Yet there are risks to the operation of referral systems, primarily potential underserving and delays in treatment.
At its best the referral system ensures that most care is contained within general practice, and when specialist care is needed patients are directed to the most appropriate specialist. However, it is also a restrictive practice, initially introduced to protect the interests of doctors, which gives general practitioners a monopoly over primary medical care and restricts patients’
freedom of choice.
Coulter (1998: 1974) In eastern Europe and in systems in which primary care is underdeveloped or has a low status compared with specialist clinics or hospital services, there is less control on the interface with hospital provision. This is a particular problem with chronic conditions that can be managed in primary care with some training and diagnostic support, such as heart failure, hypertension, diabetes, ischaemic heart disease, asthma and chronic obstructive pulmonary disease.
The expectations of the referring physician, specialist and patient often differ substantially in terms of the purpose of the referral to specialist ambu-latory care. Coulter (1998) reports widespread misunderstandings. For example, in the United Kingdom, specialists have taken over some patients referred solely for advice on management. Patients may have an entirely different set of expectations about care from both the referrer and the specialist. Financial incentives and protocols are very important in this context for defining the nature of the relationship and making explicit the reasons for referral and may also have the added benefit of reducing the duplication of diagnostic tests.
The practice of the hospital repeatedly calling patients back for further outpatient consultations in the absence of any tangible benefit for the patients is still common, although fundholding did seem to influence this in the United Kingdom. Meanwhile, communication between the ambulatory specialist and the referring physician still commonly causes problems and irritation.
Perhaps the most striking feature of the interface between specialist ambu-latory care and primary care in the United Kingdom is the very high variation in referral rates, which may differ by a factor of four for similar populations (Coulter 1998). The following factors account for some of the variation: incent-ives for general practitioners to shift work to the hospital setting; different levels of competence and diagnostic insight; sociodemographic features of practice populations (Reid et al. 1999); and lack of any explicit management or a failure to use protocols. Despite a widespread assumption that general practitioners referring high numbers of patients tend to refer unnecessarily, studies comparing referrals from physicians with high and low referral rates have not confirmed this, and thus greater use of protocols might not signific-antly affect referral rates (Knotternus et al. 1990; Fertig et al. 1993). In the
United Kingdom, at least, continuing professional development programmes seldom address known problems of over- or under-referral.
Outpatient care is changing and new models for managing this interface are developing. For example, multidisciplinary outpatient teams can provide a one-stop service for complex diagnosis and treatment (Waghorn et al. 1997).
Open-access clinics in certain specialties and conditions have also become more common within the NHS ( Waghorn et al. 1997), although the debate on their appropriateness remains unresolved. Pre-assessment clinics can be used to avoid the need for admission prior to surgery, and the follow-up of post-surgery patients after relatively simple procedures, such as hernia repair, can be dispensed with; but again, rigorous evaluation evidence is limited (Waghorn et al. 1997). New technologies also offer the opportunity to undertake many procedures on an outpatient basis that were previously dealt with in hospital.
In ambulatory emergency care, a range of models for minor treatment are emerging to treat patients who were previously seen in a primary care setting or in an accident and emergency department. Hospitals appear to be relatively efficient at providing such high-volume low-technology care (Read 1994).
Outside the physical confines of the hospital, specialist outreach clinics increas-ingly provide mainly consultant-led consultation in primary care locations (Bailey et al. 1994). Although consultant outreach clinics are popular among patients, significant questions remain concerning their costs, which are gener-ally higher per patient than traditional outpatient department clinics; they also offer less education and skill benefits to general practitioners (Gillam et al.
1995; Anglia and Oxford 1997).
Appropriateness of admission
Most patients admitted to hospital in industrialized countries have no appro-priate alternative to hospitalization. At any time, however, studies of acute hospital utilization tend to classify a sizeable minority of admissions (and an even greater proportion of inpatient bed-days) as inappropriate. Depending on the survey instrument and the study population, estimates of the propor-tion of acute hospital admissions found to be inappropriate in recent studies in the United Kingdom varied considerably. The Oxford Bed Study Instrument found zero inappropriate use (Victor and Khakoo 1994) and the Appropriate-ness Evaluation Protocol found 6 per cent of emergency medical admissions to be inappropriate (Smith et al. 1997). Nevertheless, more than 20 per cent of admissions to a specialty of general medicine and care of elderly people were assessed as being inappropriate using the Intensity-Severity-Discharge review system with Adult Criteria (Coast et al. 1995, 1996). A study in Italy using a modified variant of the Appropriateness Evaluation Protocol indicated that as many as 27 per cent of patients in a number of specialties might have been inappropriately admitted (Apolone et al. 1997). An earlier review by the authors, however, found that older studies of inappropriate hospital utiliza-tion either returned lower (less than 10 per cent) estimates of inappropriate admission or focused exclusively on inappropriate bed use (Edwards et al.1998:
236–60).
A key problem of such appropriateness studies is that, although they identify inappropriate admissions, they cannot by themselves demonstrate that an alternative form of care offering equivalent or better outcome at equivalent or lower cost actually existed for any given patient. Some studies found that only a tiny number of their supposedly inappropriately admitted patients could have gone straight home with no further care; all the others required some form of care beyond that offered routinely in primary care (Coast et al. 1995, 1996). The challenge is, therefore, to demonstrate that cost-effective measures can be implemented at the interface between primary and secondary care that ensure that inappropriate hospital admissions are diverted to more appropriate and less costly care locations.
Avoiding inappropriate admission: primary care management
Perhaps the most attractive method of managing the admission interface is to find ways to enable routine primary care management of the patient in the place of admission. Clearly, this can happen without any policy intervention when a new technology (particularly a drug therapy) becomes available to control a condition that would otherwise have required admission. Even within a fixed technology envelope, primary care management of certain acute or sub-acute conditions can still be extended and improved. Critically, the adop-tion of evidence-based shared-care protocols agreed by local primary care and specialist professionals can promote better disease management, prevent certain acute events from occurring and manage emergencies better when they do occur. Certain chronic conditions such as asthma and diabetes have proved to be particularly fertile ground for such improvements in care coordination.
Managing demand for admission
Growing attention has been paid to inserting filters at the interface between primary and secondary care; the aim is to identify patients who might not ( yet) require admission to hospital. One such filter that remains very import-ant is the operation of referral and waiting-list systems. Some conditions may prove to be self-limiting and not require intervention after a period on the waiting list, but others may not subsequently require surgery if the person dies ( Marber et al. 1991). Waiting lists can clearly be used as a tool to match demand with resource availability over time, but their efficacy, as a long-term demand management tool, remains contentious and unpredictable. Anecdotal evidence suggests that the presence of a waiting list may even increase de-mand, as patients may be referred early in case their condition deteriorates.
The implicit assumption that elective cases are less urgent than emergency cases (and hence can wait) can produce perverse outcomes, whereby patients with urgent surgical needs are forced to wait for care, while people with health emergencies are admitted to hospital when they could have been cared for elsewhere.
An important innovation in recent years has thus been the introduction of medical assessment units and admission units. General practitioners can refer health emergencies directly to medical assessment units, which are geared to providing diagnosis, observation and rapid testing, without the patient having to be admitted immediately. Integration of the medical assessment units with both hospital and community services allows an informed choice to be made as to whether patients require admission or whether they can be managed at home; in this case, the medical assessment units can mobilize and coordinate appropriate resources for home care. Medical assessment units thus sift border-line cases and take appropriate action (Gaspov et al. 1994). In parallel, admission units increasingly provide an intensively staffed environment (usually with relatively senior physicians) to allow investigation and active treatment for up to 48 hours and achieve early discharge or transfer to a non-acute setting. In other words, front-loading the acute care content of an episode allows rapid transfer (Audit Commission 1992).
Alternatives to hospital admission
The insertion of filters such as medical assessment units and admission units clearly provides a potential opportunity to divert patients to alternative care locations, thus bypassing hospital. One possible alternative to admission is to provide specialist care outside the hospital. This might involve the provision of specialist physician advice and inputs in a domiciliary setting, such as tele-phonic monitoring of fetal heart rate in high-risk pregnancies (Dawson et al.
1989), home dialysis or home visits by a specialist physician to elderly patients with congestive heart disease (Kornokowski et al. 1995). Such approaches focus on delivering technological and specialist care in a non-hospital setting.
Alternatively, other groups of patients might be diverted from hospital admission through relatively intensive nursing care in the home setting – this is the hospital-at-home model of care. Unfortunately, problems in study design and programme scale have conspired so far to prevent any robust evaluation of the use of hospital-at-home care in preventing admission (although evidence on early-discharge models is discussed below).
Not all patients who do not need admission to acute hospital can be cared for at home, because of either inappropriate home circumstances (such as poor housing or the lack of an able-bodied care-giver) or the need for con-tinuous surveillance and basic nursing care. Alternatives to acute admission for such patients do exist in the form of admission to an intermediate-care institution. Key examples of intermediate care include community hospitals, respite care in nursing homes, hospice care for the terminally ill and, more controversially, low-intensity wards within hospitals led by general practi-tioners or nurses. Once again, and with the notable exception of hospice care, very little firm evidence exists to guide policy on whether intermediate care provides a cost-effective alternative to acute hospitalization. As discussed in Chapter 4, community hospitals may provide a cost-effective alternative to acute admission, but they may also effectively add to hospital capacity and increase hospitalization rates (Baker et al. 1986). Micro-level evaluation
Table 5.1 NHS inpatient and day case activity in England, 1982–98
Inpatient cases Day cases Total cases Total per 1000 Throughput (thousands) (thousands) (thousands) population per bed All specialties
1982 5720 707 6427 137.3 16.4
1998 8459 3071 11530 233.9 43.7
Increase 48% 334% 79% 70% 166%
General and acute
1982 4709 685 5394 115.2 23.7
1998 6514 2439 9549 193.8 47.2
Increase 38% 343% 77% 68% 99%
Sources: Department of Health (1982, 1997); Hensher and Edwards (1999)
evidence on the ability of intermediate care to prevent admission is sorely lacking, and aggregate macro-level data (in the United Kingdom at least) is not adequate to demonstrate whether intermediate care is cost-effective or not.
Day care and day surgery as a substitute for admission
The massive growth in day care and day surgery in many countries is frequently offered as an example of the substitution of inpatient admission by non-inpatient care. However, considerable caution must be exercised in interpreting such claims. Table 5.1 shows the growth in inpatient and day case activity in England between 1982 and 1998. It illustrates vividly that, despite a massive increase in day case activity, inpatient admissions have continued to rise consistently. Thus, a switch towards day case work has not reduced admission rates in England. Over the same period, however, bed numbers have declined substantially (by 25 per cent in the acute hospital sector) and throughput and turnover of acute patients have improved substantially to accommodate a greater number of admissions within a smaller bed stock (Table 5.2). It could be argued, however, that a failure to expand day case activity might have prevented beds from closing and led to even more inpatient admissions than are now occurring. Nevertheless, expanded day care has almost certainly Table 5.2 NHS beds in England, 1982 and 1998
Year All specialties Acute
1982 348,104 143,535
1998 193,625 107,807
Percentage change −44% −25%
Sources: Department of Health (1982), Hensher and Edwards (1999)
contributed to earlier discharge and hence facilitated the constant increases in patient turnover observed in the NHS.
The rapid growth of day surgery has replaced a wide range of procedures that once required hospitalization, and recent developments in minimally invasive surgery and investigation and in imaging technologies are likely to do the same. Procedures such as cystoscopy, arthroscopy, laparoscopy,
The rapid growth of day surgery has replaced a wide range of procedures that once required hospitalization, and recent developments in minimally invasive surgery and investigation and in imaging technologies are likely to do the same. Procedures such as cystoscopy, arthroscopy, laparoscopy,