Shifting care from hospitals to the community: a review of the evidence on quality and efficiency.

OBJECTIVES: A key objective in many health-care systems is to shift specialist services from acute hospitals to the community and so bring care closer to home for patients. Our aim was to review published research into the effectiveness of strategies for achieving this objective.
METHODS: We conducted a 'scoping' review and qualitative data synthesis of four strategies: transfer of services from hospital to primary care; relocation of hospital services to primary care; joint working between primary and acute care; and interventions to alter the referral behaviour of primary care practitioners.
RESULTS: One hundred and nineteen studies were identified and data systematically extracted. The findings suggest that transferring hospital services to primary care, and interventions that change the referral behaviour of primary care practitioners generally reduced outpatient activity but also risked reducing quality. Savings in cost were offset by increases in overall service volume and loss of economies of scale. Relocating specialists to primary care, and joint working between primary and acute care, improved access without jeopardizing quality. However, outpatient activity was rarely reduced and costs were generally increased due to loss of economies of scale.
CONCLUSIONS: Our findings suggest that the policy may be effective in improving access to specialist care for patients and reducing demand on acute hospitals. There is a risk, however, that the quality of care may decline and costs may increase.