Paediatric ‘care closer to home’: Stake-holder views and barriers to implementation
Introduction
The shift of healthcare from hospitals into community settings has been a theme running through policy for paediatric health services in the United Kingdom since the Platt Report in 1959 (Ministry of Health, 1959). Based on the philosophy that families' lives should continue as normally as possible when children require medical treatment, National Health Service (NHS) reforms have sought to ensure that children and young people who are ill receive timely, high quality and effective care as close to home as possible (DoH, 2004). New treatments and technologies in conjunction with a need to reduce demand on acute hospitals (Department of Health, 2006, Roland et al., 2006) have accelerated this initiative, which is also presented as desired by families (DoH, 2004).
Many of the Care Closer to Home (CCTH) evaluations carried out to date have focused on adult outpatient services (Bowling et al. 1997; Bond et al, 2000; Bowling and Bond, 2001, Roland et al., 2006, Sibbald et al., 2007), or on preventing inpatient admission and reducing length of stay (Parker et al., 2011a, Parker et al., 2011b). Thus despite a policy drive for paediatric CCTH, there remain gaps in existing evidence about the appropriateness of this model for specialist paediatric outpatient services, namely the acceptability of the model by parents, patients and healthcare professionals, and the extent to which any of the proposed benefits have been achieved (McLellan, 1995).
Studies evaluating the shift of specialist adult care from large hospitals to smaller community settings have produced mixed findings. The reports of an initial evaluation of CCTH demonstration sites (Roland et al., 2006, Sibbald et al., 2007) concluded that moving specialist care into the community has the potential to lead to better communication between General Practitioners and consultants, to improve patient experience, and to provide better access to specialist services. On the other hand, the initiative runs the risk of compromising the quality of care that patients receive and may lead to increased costs with less efficient use of consultants' time. Two systematic reviews of specialist outreach clinics, including adult and paediatric care (Gruen et al., 2009, Powell, 2002) and evaluations of specialist outreach clinics in General Practice (Bowling et al. 1997; Bond et al., 2000 Bowling and Bond, 2001) have reported an increase in patient satisfaction and improved processes of care, but negligible effects on health outcomes and service costs. Studies specifically evaluating the shift of children's specialist outpatient services into community settings are rare. One study which has described and evaluated consultant-led paediatric clinics (Spencer, 1993) concluded that these services can improve choice and access, while facilitating effective patient management and clinical-decision making, particularly in ‘deprived areas where the need is greatest’ (Spencer, 1993, p500).
Initiatives such as CCTH have led to a number of specialist services being delivered in non-traditional places such as the home and community facilities (Williams, 2002). New conceptualisations of healthcare places are emerging which view them as more than their physical location and material environment (Rapport et al., 2007). Rather, they are understood as social domains which ‘encompass our response to our surroundings and performance within in it’ (Rapport et al., 2009, p315). Hence healthcare spaces provide experiences, attachments, symbolism and identity for their users (Andrews, 2006). This understanding of place beyond physical location and setting has led to a consideration of the meanings attached to where care is delivered, and how different stakeholders participate in the creation of new health places (Lehoux et al., 2007). Thus place and space are becoming increasingly important features in where and how families access healthcare.
The aim of this study was to explore healthcare professionals' and other NHS stakeholders' views and experiences of providing consultant-led paediatric outpatient clinics in both the traditional hospital setting, and in less traditional community settings, with a particular interest in how the place of service delivery might influence organisational processes, practices and clinical norms. Such an exploration is important because healthcare professionals and other NHS stakeholders can significantly facilitate or constrain policy implementation through their professional attitudes and behaviours (Bowling and Bond, 2001). Their engagement is thus imperative to the success of service redesign initiatives such as CCTH (Munton et al., 2011, Sibbald et al., 2008, Ritchie and Spencer, 1994).
Section snippets
Study design and setting
This evaluation was carried out in collaboration with a specialist children's hospital in the United Kingdom and surrounding primary care trusts, situated in a large, diverse, urban area. The hospital currently provides two consultant-led general paediatric outpatient clinics in community settings; one in a health centre and the second in a ‘Sure Start’ children's centre, which offers a range of community-based support services for families. The use of semi-structured interviews enabled
Results
The sample, in total 37, included: nine consultant paediatricians specialising in General Paediatrics, Emergency Medicine, Dermatology and Respiratory Medicine; six General Practitioners; three paediatric Registrars specialising in Metabolic Diseases, Neurology and Paediatric Intensive Care; six other healthcare professionals (HCPs) including three Clinical Nurse Specialists, one phlebotomist, one Occupational Therapist and one Health Visitor; seven NHS executive team members; four NHS service
Discussion
Many of the hospital-based participants in this study positioned the hospital at the top of a healthcare hierarchy, presenting their ways of working as the ideal standard of care. Similar to the findings of a Canadian study on satellite dialysis units (Lehoux et al., 2007), hospital based professionals appeared keen to retain their professional culture and organisational practices regardless of place, promoting a ‘mini-hospital’ approach to paediatric outpatient CCTH. In contrast, primary care
Conclusions
Our findings demonstrate that from the service provider perspective the place of service delivery is not only an issue of physical location and supportive infrastructure, but also involves professional and organisational identities. Policy initiatives which ignore assumptions about place, power and identity, or which challenge them too strongly, are likely to meet with limited success (Currie et al., 2009). Shifting outpatient clinics into the community will require physical relocation as well
Acknowledgement
This work was funded by the National Institute for Health Research (NIHR) through the Collaborations for Leadership in Applied Health Research and Care for Birmingham and Black Country (CLAHRC-BBC) programme.
The views expressed in this publication are not necessarily those of the NIHR, the Department of Health, NHS Partner Trusts, University of Birmingham or the CLAHRC-BBC Theme 2 Management/Steering Group.
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