Shifting healthcare services from hospitals to community settings: implications for health inequalities – a systematic scoping review

Background There is an increasing global focus on shifting healthcare provision from hospitals and into community settings, partly with the aim of reducing health inequalities. This study aimed to (i) ascertain which non-emergency hospital-based healthcare services have been shifted to community settings and (ii) to understand the impact of these shifts on health inequalities. Methods A systematic scoping review of five databases, alongside extensive hand searching, was conducted. Eligible studies used qualitative or quantitative methods, were peer-reviewed, published in the English-language, from 2015 onwards, and examined any population in high-income countries. After deduplication, one reviewer screened the titles and abstracts, followed by the full texts; a random 10% sample checked by a second reviewer at both stages. Data were extracted from eligible studies, checked for accuracy, charted, and narratively summarised. Reported beneficial outcomes of shifting healthcare provision from hospitals to community settings were mapped onto the Quadruple-Aim framework. Results Of the 28 included studies, 9 were from the UK, and 10 focused on long-term condition management services. Reported beneficial outcomes of service shifts included: better overall patient experience than standard hospital-based care ( n = 10), and fewer referrals to hospital-based secondary care ( n = 8). Most ( n = 21) studies did not report service shift drawbacks, limiting scope for a balanced assessment. However, of the 7 that did, one community service found no reduction in secondary care waitlist length, and another reported a higher non-attendance rate in the community setting than hospital-based care. Evidence on health inequalities (e.g., age, sex, ethnicity, and socioeconomic position) was limited: only 7 studies examined variation in outcomes (e.g., access, onward referral, and satisfaction) across population groups. Of these, 4 found no differences, 2 reported better access for some groups, and 1 reported poorer access. Conclusions Shifting healthcare services from hospitals to community settings has the potential to improve patients' experiences of care, improve population health, reduce healthcare costs, and enhance the experience of providing care. However, there is currently limited evidence to suggest that these shifts reduces health inequalities. Robust evaluations, including analyses of inequalities in patient outcomes, of services shifted to community settings are warranted.