TableA.1 Developments in service delivery: summary of articles examined for shared care

ID and authorsResearch setting and year of studyStudy designSample sizeTopic of documentKey results and conclusionsLevel of evidenceQuality score (AGREE) (%)
Kennedy et al683UK (1999–2000)RCT700 PatientsImpact of a guidebook for self careA whole systems approach to self management using a guidebook developed with patients and with physicians trained in patient centred care improves clinical outcomes and leads to cost effective use of NHS services. This method should receive more widespread use in chronic disease management, and seems likely to improve patient satisfaction and reduce health expenditure without evidence of adverse effect on disease control. Evidence suggests that further attention needs to be placed on self referral and access arrangements and a redistribution of control to patients through increased adherence to patient centred norms on the part of consultants193
Williams et al679UK (1995–96)RCT180 PatientsOpen access follow-up for IBDOpen access follow-up delivers the same quality of care as routine outpatient care and is preferred by patients and GPs. It uses fewer resources in secondary care, but total resource use is similar. Better methods of ensuring urgent access to outpatient clinics are needed173
Robinson et al681UK (2001)RCT203 PatientsGuided self management and patient directed follow-upSelf management of ulcerative colitis accelerates treatment provision and reduces doctor visits, and does not increase morbidity. This approach could be used in long term management of many other chronic diseases to improve health service provision and use, and to reduce costs. Nursing staff, appointment clerks, and secretarial teams need to be willing to assist with implementation of changes, and one person from the medical team needs to be available for patients to contact for advice166
Shepperd and Iliffe689International (1996–2001)Systematic review16 TrialsHospital versus home careThis review does not support the development of hospital at home (active treatment by healthcare professionals in the patient’s home) as a cheaper alternative to inpatient care. Providing that the views of carers are taken into account, early discharge schemes for patients recovering from elective surgery and elderly patients with a medical condition may have a place in reducing the pressure on acute hospital beds166
Kennedy et al682UK (1999–2000)RCT700 PatientsSelf management in IBDAdoption of guided self management was generally popular with both patients and clinicians, reduced use of hospital services without burden to primary care, and increased quality of care without an adverse effect on disease control at the same time as reducing cost. More widespread adoption of this programme for patients with IBD and other chronic medical disorders, particularly those with relapsing remitting patterns, now seems indicated175
Ham et al675Comparison between UK and USA practice (2000–01)Analysis of routine dataHospital episode data for 2000 and 2001; data from Kaiser and Medicare systemsComparison of hospital bed useThere is scope for hospital beds to be used in a different way in the NHS; primary and secondary care should be integrated to give priority towards self care; the NHS can learn from the Kaiser approach2−66
O’Hanrahan and Irving688UK (1992; data taken between 1977 and 1991)Analysis of routine data400 RecordsRole of HPNRecent reports have highlighted the palliative benefits of HPN, and the way in which it facilitates compassionate home care for carefully selected patients with inoperable malignant bowel obstruction. However, it is unlikely that the current financial constraints within which the NHS operates could cope with the demand associated with HPN2−66
Evans et al686Canada (1996–2000)Analysis of routine data15 PatientsHome total parenteral nutrition (HPN)Patients receiving HPN benefit from reduced stress on the family, increased independence, and ability to perform normal work and study activities. All patients preferred HPN to hospitalisation and reported good or excellent quality of life. HPN is a safe alternative to hospitalisation or early surgery of patients with the complication IBD2−61
Kennedy et al684UK (2003)Survey of patients147 ResponsesDevelopment of self help book for patients with IBSGuided and practical ways of support are required for people with IBS who want to self manage their condition. Patient information is essential for shared decision-making, but most information is not patient centred and often does not involve the patient at all. All information should include patients at each development stage2−57
Robinson680UK (2004)Expert commentaryNAIBD and patient empowermentSelf care is a normal human function and accounts for the management of three quarters of all episodes of ill health. More formalised applications include patients and doctors working collaboratively to develop a set of guidelines which patients use to manage their chronic disease themselves. Clinicians may be reluctant to pass control of treatment changes to patients, particularly the use of steroids. There are indications that passing ownership of management back to patients may improve compliance as patients realise their own responsibilities for remaining well359
DoH674UK, NHS (2004)Strategy and commentaryNAImproving chronic disease managementA key approach to managing chronic disease is to support people to take an active role in managing their own care, specific conditions, and approaches that prevent these conditions from getting worse. This is linked with the development of GPwSI to provide patient centred care339
RCP and RCGP677UK, NHS (2004)Report/commentaryNAService provisionThere should be active support for the development of GPs with special interests467
BSG and RCP489UK (2003)Expert commentary and recommendationsNAGI service provisionServices and high quality care for patients and their families should be delivered locally whenever possible. Emphasis should be placed on integrating primary and secondary care, and moving hospital services closer to the patient443
DoH673UK, NHS (2004)National framework and commentaryNAOutline of plans for national standardsEmphasis on the importance of improving the whole experience of patients, with particular attention to tailoring services to patients with long term conditions, promoting independence for older people, and supporting self care and the expert patient436