What is a community hospital?
Community hospitals mean more to communities (inclusive of patients, carers, staff, volunteers and other local residents) than simply a place to receive health care.
National mapping identified 296 community hospitals (with beds) in England in 2015, although detailed data were available for only 267 of them. Analysis of the 267 sites showed that community hospitals with beds typically were:
- were small – 70% of community hospitals had ≤ 30 beds
- were rural – 78% were based in rural or significantly rural areas
- were led by general practitioners (GPs), in-house doctors and nurses – historically GPs have been an integral part of community hospital provision and their involvement remains significant, but it has reduced, whereas the in-house employment of doctors has grown; in practice, most community hospitals are nurse led
- were without 27/4 medical cover – community hospitals do not have 24/7 on-site medical cover and
- are reliant on nursing staff and out-of-hours doctors outside core hours
- provided step-down and step-up care for frail, older inpatients
- had an average length of stay of < 30 days (median 24 days; mean 27 days)
- had a range of additional local, intermediate and generalist care services on a spectrum from primary to acute care orientations.
Other common characteristics we identified, highlighted the ‘dynamic reality’ of community hospitals at a local level, they were also typically:
- Historically embedded within and valued by their local communities.
- Operating with complex models of ownership and provision.
- Providing a valued, relational model of care.
- Based on integrated, multidisciplinary working.
- Constantly evolving in response to external demands. Significant recent developments include a reduction in inpatient beds, withdrawal of GPs, a shift towards step-down provision and a growing acuity of patients.
How do patients and carers experience community hospitals?
Relationships between patients, their families, staff and community members and relationships between all these people and their environments were an intrinsic factor in people’s rehabilitation and recovery.
People said that it felt different being a patient in a community hospital compared with elsewhere: it felt more like home because of its location and familiarity, environment and atmosphere, and the relationships between staff, patients, families and the community. People described a holistic and personalised approach to care, which was particularly valued as admission to hospital was often associated with difficult changes in personal circumstances.
Patients and carers particularly valued four dimensions of community hospitals:
- Environmental and functional features of community hospitals such as their locations, accessibility, surroundings, interiors, food and atmosphere.
- Interpersonal aspects of care, such as relationships between staff, patients and family carers. Patients described warm and welcoming staff, being looked after personally with sensitivity and respect, staff (and volunteers) spending time with them, being listened to, keeping their spirits up and time taken to care for the whole person.
- Social aspects of patient experience included the importance of having family and friends close by so that they could be visited often and the importance of the hospital being community based, thereby increasing the chance of meeting familiar faces and being known, and of maintaining (a social) life rather than pausing it.
- Psychological aspects of patient experience included feeling less anonymous and frightened, feeling more confident and hopeful, while also coming to terms with loss and change. Although community hospitals were generally seen to build patients’ confidence and physical health, a greater focus on psychological, emotional and mental health was identified as needed.
But context and flux affects patient experience…
These elements were all subject to context and were in flux; for example, functional aspects of patient experience were changing as patients were drawn from an increasingly wide geographical area, whereas, in other cases, the interpersonal aspects were challenged by pressures on staff, recruitment challenges and growing pressures on beds.
What does the community do for its community hospital and what does the community hospital do for its community?
What does the community do for its community hospital?
Communities support their local hospitals in four key ways:
1. Giving time – community hospitals, identified as having a League of Friends (or equivalent) registered with the Charity Commission, involve 24 volunteers on average, suggesting the involvement of 5880 volunteers across the 245 community hospitals. This is estimated to equate to between 1.4 and 2.5 full-time equivalent personnel per hospital, at a national value of between £3.8M and £6.9M. Volunteers were drawn predominantly from older age groups, raising concerns about future sustainability. Limits to the involvement of volunteers included a perceived lack of investment in their recruitment, co-ordination and support beyond that provided by the League of Friends or individual hospital staff.
2. Raising money – in 2014, community hospital Leagues of Friends generated an average income of £45,387 (median £15,632). Two-fifths of all income to Leagues of Friends came from legacies. There was considerable variation in levels of income across community hospitals that could not be explained solely by levels of deprivation but instead appear to be influenced by a range of community- and hospital-level factors. Average levels of income also vary over time: since 1995 the charitable income of Leagues of Friends has declined by an average of £901 a year.
3. Providing services – beyond the service delivery roles of individual volunteers and Leagues of Friends, various voluntary and community groups also contribute to community hospitals through the provision of a wide range of services and activities both within and outside the hospitals.
4. Giving voice – despite a long history of community involvement in strategic decisions about community hospitals, the mechanisms and depth to which this happens vary considerably. There was considerable frustration expressed about the ability of communities and individuals to influence decisions, both within specific consultation exercises and on a more sustained, continuous basis.
But variations exist….
Variations exist in the level of support that communities provide to community hospitals in the following ways:
- Between communities – this could not be explained by levels of prosperity/deprivation alone but was influenced by the history of the hospital, the local geography and the service and provider mix.
- Within communities – there was a particular dominance of older people among those who were most active in their support.
- Over time – quantitative evidence showed the dominant trend was one of decline, particularly in terms of income, although this was not raised as a particular concern among the case studies.
What does the community hospital do for its community?
Community hospitals fulfil a number of important functions within the communities in which they are based and provide significant value. They represent a significant community asset, with a strong sense of community ownership. Their provision of local, accessible health and social care services has an important practical and symbolic significance, particularly in more isolated rural communities. We found evidence that community hospitals can contribute to six distinct areas of ‘community value’:
1. Instrumental – primarily through the provision of local, accessible and integrated intermediate health and social care services.
2. Economic – through the provision of local employment and the reduction of travel costs associated with accessing more distant health-care services.
3. Human – through the development of skills and confidence among, not just staff (and patients), but also volunteers.
4. Social – through the development of networks of interaction, trust and reciprocity, built directly through the services provided by the community hospital and indirectly through community engagement activities.
5. Cultural – through a sense of identity, belonging and civic pride for individual staff and volunteers, and across the community through a collective sense of place.
6. Symbolic – as a symbol of vitality and viability of the community, community hospitals contribute to perceptions of resilience and autonomy and as a source of security and reassurance.