Community Hospitals – Discovering a New Model of Care?
By Dr Helen Tucker (President, Community Hospitals Association)
Community Hospitals evoke emotions of loyalty, passion and pride from their local communities. A sense of "ownership" comes from the fact that these small rural hospitals were built and sustained by the communities themselves before the NHS, and have provided a place of care and healing for generations. Local support manifests itself through ongoing promotion, fundraising and volunteering and can reach new heights when there are threats to withdraw services or even close community hospitals.
For over 150 years, these small rural hospitals have provided "care closer to home", "intermediate care" and "integrated care" (Pitchforth et al, 2015; Tucker, 2013) and arguably their role and function chimes well with the NHS national strategy for England as set out in the Five Year Forward View. The community hospital concept fits well with new models of care, such as in Sussex where they are part of the Primary Care Home Model and as demonstrated in Morecambe Bay where they are part of a vanguard for PACS Primary and Acute Care System. The features of this generalist model of care that are so highly valued include "being treated as a whole person", being close to friends and family, having continuity of care, and the "quiet and home-like atmosphere" (Lappegard et al, 2014). This would appear to be consistent with the ambition of the NHS to provide appropriate, high quality, person-centred care, and align well with "new" models of care.
However many of these valued features now risk being compromised. For local people, their hospital may look the same as it did twenty years ago. But step inside the door, and the changes are fundamental.
A major change is the ward provision. Nearly 100 of community hospitals in England no longer offer inpatient facilities, (just under one third of all community hospitals) and those that have wards may have fewer beds than before. The beds that are there are likely to be fully occupied, but not all by local people. The high utilisation rate is achieved in many areas through an efficient centralised bed management process which places patients wherever there is a spare bed across a wide geographical area, rather than in their local community hospital.
Another change is the closure of many minor injuries units. Accessible urgent care provision is being redefined, as patients now have to travel outside of their area.
Community hospitals without beds or a minor injuries unit do not need to open at night or weekends. There is also the question of how to use the space. There are ideas from commissioners that the space is used for social care, welfare, a base for community teams, and for wellbeing rather than health services – referred to as a "community hub".
The enthusiasm by commissioners for community hubs is not yet matched by support by local people in many areas. Ways need to be found to engage productively with local people, and to ensure that the newly designed community hubs retain the concept of care of the community hospital and make a contribution to health and wellbeing. So far progress on this has been slow. For instance, a proposal by a CCG for a closed ward to be converted to a community café was greeted by incredulity in a popular tourist town with local businesses including many cafes near to the hospital.
Walking through the door, you may now be greeted by staff in a variety of uniforms and badges of many different organisations. in one small hospital I counted 11 different service providers including private companies such as Virgin Care. Many community hospitals are now owned by NHS Property Services Company Ltd. Managers have reported to me on my visits that procurement exercises have resulted in contractual arrangements are of disproportionate complexity to the size of the service, and create an operational challenge to integration and continuity. I would equate this to changing the service from being a local corner shop to being more like a shopping mall. In the corner shop you have a local familiar service. In the shopping mall, space is rented by national, regional and local suppliers and can be changed frequently.
So when the general public look at their local hospital, it appears to be the same as it was before. In consultations and public meetings, I have heard local people articulate the role of the community hospital in many ways including: providing an accessible and familiar local service, saving patients and families from travelling, providing an holistic service from the cradle to the grave, offering rehabilitation to promote independence, providing a place for end-of-life care, and offering continuity of care. The concept and the model of care appears to be the same as it was when the hospitals were first established, but the (un)intended consequences of policy and systems are such that the concepts of localness, place-based care and extended primary care are being challenged. When you go through the front door now, the service is now quite different. And in some cases, the front door is often closed.
The challenge will be to find ways of developing new models of care that retain those features of community hospitals that are so highly valued by local people, and which make a significant contribution to the health care system. Community hospitals have been shown to have a long tradition of local, accessible generalist care that can be provided to mainly rural communities in a sustainable way. This "old" model of care with its long tradition should not be overlooked, and ways found in which community hospitals have a strategic role and can be seen to be an integral part of "new" models of care.
NB.: The Health Services Management Centre has been carrying out research on community hospitals funded by the NIHR and is asking the questions: "Where are they, what do they do, what do patients think of them and how are communities involved?" The study is a collaboration which has included the Community Hospitals Association, and will report new knowledge and evidence on community hospitals in respect of their role and value in providing local health care. The findings of the study will be eagerly awaited by all those concerned with community hospitals and rural healthcare provision.
*** Photograph used with kind permission of the Community Hospitals Association ***