Improving efficiency and effectiveness of outpatient services: a review of interventions at the primary–secondary care interface

Problem

Variation in patterns of referral from primary care can lead to inappropriate overuse or underuse of specialist resources. We review the literature on strategies involving primary care that are designed to improve the effectiveness and efficiency of outpatient services.

Approach

This scoping review updates a previous review by Roland et al. (2006). We conducted a systematic literature search and qualitative evidence synthesis of studies across five intervention domains: transfer of services from hospital to primary care; relocation of hospital services to primary care; joint working between primary care practitioners and specialists; interventions to change the referral behaviour of primary care practitioners; and interventions to change patient behaviour.

Findings

184 studies were identified. Taken with the findings of the previous review, the findings suggest that transfer of services from secondary to primary care and strategies aimed at changing referral behaviour of primary care clinicians can be effective in reducing outpatient referrals and in increasing the appropriateness of referrals. Availability of specialist advice to primary care practitioners by email or phone, and use of store-and-forward telemedicine, also shows potential for reducing outpatient referrals and hence reducing costs. There was little evidence of an effect of relocation of specialists to primary care, or joint primary/secondary care management of patients on outpatient referrals. Across all intervention categories there was very little evidence available on cost-effectiveness.

Consequences

Our review suggests a number of promising interventions which may improve the efficiency and effectiveness of outpatient services, including making it easier for GPs and specialists to discuss patients by email or phone. However, there remain substantial gaps in the evidence, particularly on cost-effectiveness, and new interventions should continue to be evaluated as they are implemented more widely. For new types of organisation such as the Multi-Specialty Community Providers suggested in the NHS Five Year Forward View, a move for specialists to work in the community is unlikely to be cost effective unless they make significant additional input – e.g. enhancing GPs’ skills through education or joint consultations with complex patients.