SHIFTING SERVICES GUIDANCE
April 2015

Shifting services is an organising principle for the design and delivery of health services. It is an umbrella term used to describe a range of processes aimed at delivering the right care, in the right place, at the right time, by the right person or people. It involves working together to ensure the right mix of activities for patients are delivered in the right mix of places, so that patients can access personalised, high-quality care, conveniently and safely, as close to home as possible. Patients must remain at the centre of any service reconfiguration.

District Alliances are the appropriate forum for this service development as they are based on a partnership approach which aims to provide what is best for the system, not individual providers. Using the Alliance ensures all service reconfiguration is co-designed. The principles that underpin shifting services are:

  • Collaborative working between clinicians and managers, hospital and community based services and different health professionals.
  • A systematic approach must be taken to service reconfiguration.
  • Agreeing that only those services that need to be delivered from a hospital setting will be unless the costs (to all parties) are prohibitive.
  • Quality and safety of care.
  • Having the right infrastructure and pathways in place – including appropriate capacity/capability in primary care.

International literature suggests the following needs to be considered when shifting services:

  • Heterogeneity of approach – Local context is important. Local circumstances, objectives, demands, resources and capabilities need to drive shifting services (including which specific services) if it is to be a success.
  • Success in shifting services is not just luck – necessary preconditions before embarking on shifting services:
  • Staff, skills and knowledge – including the presence of support for clinical leaders; expertise in data analysis, project planning and management, and evaluation and access to data – including shared information systems.
  • Culture and values – including strong clinical-management partnerships, a quality improvement culture within participating organisations, and willingness by the fund-holder to innovate, release funding, or fund services more flexibly.

Examples of shifting services are varied based on local need, context and scalability. This could range from co-locating out-patient clinics into the community, through to substantial redesign of service structures, resourcing and facilities. Not all clinical pathways are considered a shifted service. Those clinical pathways that identify best practice but do not provide improved access to diagnostics or services are not considered shifted services.

The approach to shifting services can be broken into four broad categories:

Approach to shifting services / What this means / Examples
Substituting skills / Shifting services so that care is provided by the right person / Discharge follow-up by primary care, supported self-management, clinical nurse specialists, primary care provision of services, nurses as lead clinicians for certain patients, greater use of allied health, navigators
Integration / Bringing organisations and professionals together with the aim of improving outcomes for patients through delivery of integrated care / Disease management programmes, care pathways, case management, care co-ordination, integrated IT solutions, bridging across specialist community services
Simplifying access / Providing better access to services closer to home, by bringing care to the patient and/or simplifying referral pathways from community based care / Specialist out-reach clinics, community based diagnostics, hospital-at-home, GP direct access to hospital-based tests
Professional support / Providing support for primary care to manage a wider range of patients and to reduce avoidable referrals / Specialist nurses or physicians providing support, advice, peer review for primary care practitioners, medication reviews, structured referral sheets

Further examples:

  1. Services that will continue to be provided in hospital or ‘specialised’ settings but where access from primary care can be improved eg diagnostics:
  • Radiology
  • Neurology diagnostics
  • Exercise ECGs
  • Endoscopies
  • Gynaecological procedures such as colposcopy
  • Improved access to specialist advice to support community-based management eg mild to moderate mental health conditions
  • Direct community referrals to Assessment Treatment and Rehabilitation
  1. Services that can be shifted and delivered by primary care professionals in community settings (based on agreed pathways) with little or no need for additional investment in plant or training:
  • Respiratory function examinations eg spirometry
  • Audiometry services
  • Post discharge follow-ups
  • Management of specific conditions – eg cellulitis, sleep apnoea, deep vein thrombosis
  • Community nursing services including District, Publish Health and Child Health
  • Services that are part of the on-going care of people with long-term conditions/including retinal screening, podiatry and dietetics
  • Needs Assessment and Service Co-ordination
  • Additional minor surgery and treatment of skin lesions
  • Joint injections and aspirations for musculo-skeletal conditions
  • Diabetes services such as commencing newly diagnosed Type 1 diabetics on insulin and training in self-management
  • Supported management of chronic conditions
  1. Services that are (and will continue to be) provided by ‘specialists’, which are currently delivered in hospitals or specialist settings but which can be delivered just as readily in community settings (including through telehealth):
  • First specialist assessments
  • Post-discharge follow-ups
  • Diagnosis and management of both acute (eg dermatological) and chronic (eg cardiovascular) conditions.
  1. Services that can be shifted but which require investment in plant and/or workforce training before they can be delivered by primary care professionals in community settings:
  • Post-acute cardiac and pulmonary rehabilitation – shifting follow ups in these and other areas is felt to have more potential value than currently being realised
  • Stepped care for mild to moderate mental health issues
  • Intermediate care for older people
  • Drug and alcohol addiction services.

Acknowledging that DHBs are all at different stages of service reconfiguration, particularly shifting services, DHB Annual Plans for 2015/16 will be individually assessed. Assessments will be based on:

  • Scale – population size
  • Alliance maturity
  • Historical context – where each DHB is in the ‘integration journey’
  • Capacity and capability
  • Sufficient enablers
  • Provision of volumes and/or budgets – this will be assessed against individual services as appropriate, eg a co-located specialist clinic that also provides professional support to GPs and nurses will not be required to provide volumes and/or budgets.

Some DHBs are well along the ‘integration journey’ and will not be required to provide the level of specificity (eg which ‘three’ services are to be shifted this year) of other DHBs who are still starting the ‘integration journey’.

DHBs who are still early in this journey or who have not yet selected services to be shifted for 2015/16 may provide ‘process’ quarterly milestone such as:

  • Quarter One – confirm project plan (including development of necessary enablers) and clinical/managerial governance
  • Quarter Two – identify services to be shifted
  • Quarter Three – confirm implementation plan, including budget and/or volumes
  • Quarter Four – begin implementation.