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In 2006 in England, the Government heralded a new direction for community services[i], focusing on care closer to home with a call for commissioners to shift resources from secondary care to the community, wherever it was cost effective and beneficial to local people. The fundamental driver for this care closer to home policy was the need to stem the flow of unnecessary hospital admissions into acute care.[ii] The potential for outpatient tests, clinics and treatments taking place in community settings and replacement of acute bed days through better use of community hospital (CH) services and intermediate care facilitating early discharge or admission prevention, were key themes in this shift of services and resources. A financial commitment was made available to develop CHs as a key element of a strategy to create capacity for integrated health and social care services. However, by 2010, the Audit Commission [iii] suggested little progress had been made in England with unplanned emergency admissions growing at 3% per annum.
There are a number of interdependent issues insufficiently addressed in previous research on Community Hospitals, which need to be understood. Our interest is to map, explore and understand three specific issues:
Community hospital definitions and functions
A lack of robust research means little is known of the numbers, distribution and facilities offered by community hospitals [iv]. While this has been addressed to some extent in previous work [v][vi][vii][viii][ix] the increased emphasis on a primary care-led NHS, together with different national approaches, means the contrasting characteristics and differences in client groups, range of services, organisations involved and ownership makes classification complex.
As we know little about the overall numbers, distribution, facilities and services offered by CHs, we will conduct a national mapping exercise. The data from this exercise will enable us to construct a national database and directory, and work with the Community Hospitals Association to provide this as an open resource on their website. This element will have five key phases:
- reconciliation and consolidation of existing national data sets of CHs.
- construction of a national database of CHs.
- conducting a national survey of CHs (drawing on the Young study).
- developing a directory of CHs and accessible web-based resource at the CHA.
- developing a typology of CHs.
Nine case study sites in England will be selected, and two further areas of research undertaken.
NHS services, particularly hospitals, are consistently rated highly [x] with patients rating doctors the most trusted and respected professionals. [xi] However, as a result of a series of major healthcare scandals in the last 20 years, community campaigning groups, the media and politicians have all made the quality of NHS care a matter of public concern. National campaigns to address this have emerged, focusing on areas such as respect, dignity [xii] and patient safety, [xiii] and improving patient experience is a key priority. [xiv] More recently, the scandal into patient deaths at Mid-Staffordshire NHS Foundation Trust [xv] highlighted the poor quality of care and re-emphasised the need for compassion.
The trend towards 'bigger is better' arguments in favour of larger healthcare institutions, along with increased use of technology as a cost saving mechanism, are depersonalising patients' experiences and their need for a 'connected and reciprocal relationship with staff'. [xvi]
Against this background, some studies appear to suggest that patient satisfaction and outcomes of care in CHs compare favourably with other models of care, [xvii] with patients saying that they are treated as an individual. [xviii] However, little systematic research has been undertaken on patient experiences in CHs, and the evidence base for such claims remains under-developed.
We will explore and understand the nature and extent of patients' experiences of community hospital care and services, focusing on five areas:
- Organisational and Human Factors
Local community hospitals are known and valued by their communities, [xix] and play an important part in responding to the health and social care needs of local populations. They help to take pressure off acute hospitals by treating people locally so they do not have to go into a big general hospital or as a step down from a big general hospital as part of rehabilitation. [xx]
Support for, and satisfaction with, CHs by the public, patients and staff remains steadfast, [xxi] as does professional support from GPs. [xxii] However, given the lack of research into the wider role that CHs may play in the communities in which they are located, this is a key focus of our study, and provides an opportunity to general new knowledge.
In particular, we seek to establish the extent to which community engagement can be encouraged, nurtured and developed, and understand the variations in community engagement, and consequently the scope of and limitations of policies predicated on community support.
This study seeks to:
- Construct a national database and develop a typology of CHs.
- Explore and understand the nature and extent of patients' experiences of community hospital care and services.
- Investigate the value of the interdependent relationship between CHs and their communities.
we will do this through drawing on a review of the literature on community hospitals and services; a mapping exercise (numbers, location, size, age, services); and nine case studies examining and comparing community hospitals in England, looking at patient experience and the ways in which local communities are involved with their local hospitals.
The research will be conducted over a period of 36 months commencing September 2014.
September 2014 - August 2017
Jon Glasby, Deborah Davidson, John Mohan, Iestyn Williams, Angela Ellis-Paine and Daiga Kamerade, Russell Mannion, Nicholas Le Mesurier, Tessa and John Crilly (Crystal Blue Consulting), Helen Tucker (Community Hospital Association), David Seamark (Community Hospital GP lead), Bradford Institute for Health Research (Prof. John Young) and RAND Europe (Dr Ellen Nolte).
From this research, we will produce:
- A plain language executive summary, full report and a short document for each case study site, detailing key findings on patient experience, community value, the role of the CH in the local health and social care context and community, and implications for commissioning.
- A UK wide map and comprehensive database of community hospitals.
We will involve service users, carers and local community members throughout the research, on a cross study National Steering Group, through local Reference Groups and through Annual Learning Events (we plan to bring people from across all nine case study sites together on an annual basis, to share experiences, best practice and network).
The first of three annual learning events was held on 22 March 2016 at the University of Birmingham. A group of representatives from the UoB Community Hospitals research team and case study hospitals, spent a productive day together exploring definitions of community hospitals. Professor Jon Glasby (UoB) provided an overview of the current policy context within which community hospitals are operating. Key themes highlighted included: personalisation; partnership; care closer to home; and quality versus costs. You can see a recording of Jon's presentation here.
HS&DR - Community Hospitals
[i] Department of Health (2006) "Our Health, Our Care, Our Say: A new direction for community services". London: Department of Health.
[ii] NHS Benchmarking Community Hospitals - Report (124 CH).
[iii] Audit Commission (2010), "More for Less: Are productivity and efficiency improving in the NHS?" London: Audit Commission.
[iv] Seamark, D, Moore, B, Tucker, H, Church, J and Seamark, C (2001), "Community hospitals for the new millenium". British Journal of General Practitioners, 51(463):125-127.
[v] Tucker, H (1987a), "The Role and Function of Community Hospitals - King's Fund Project Paper Number 70". London: King Edward's Hospital Fund for London; Tucker, H, Moore, B, jOnes, S and Marriott, J (2008) "Profiling Community Hospitals in England 1998-2008". Community Hospitals Association: Department of Health and Community Health Partnership.
[vi] Heaney, D, Black, C, O'Donnell, CA, Stark, C and van Teijlingen, E (2006), "Community hospitals - the place of local service provision in a modernising NHS: an integrative thematic literature review". BMC Public Health, 6:309.
[vii] Ritchie, LD and Robinson, K (1998), "Community hospitals: new wine in old bottles." British Journal of General Practice, 1039-1040.
[viii] Seamark, D, Moore, B, Tucker, H, Church, J and Seamark, C (2001), "Community hospitals for the new millennium", British Journal of General Practitioners 51(463): 125-127.
[ix] Department of Health, Our Health, Our Care, Our Say (2006) op cit.
[x] Coulter, A (2005), "Trends in Patients' Experience of the NHS". Oxford: Picker Institute; Healthcare Commission (2007) "Survey of Adult Inpatients in the NHS 2007". London: Healthcare Commission.
[xi] Ipsos Mori (2008), "Trust in Professions 2007: Public awareness of physicians and trust in professionals - research study conducted for the Royal College of Physicians". London: Royal College of Physicians.
[xii]Royal College of Nursing (2008), "Defending Dignity - Challenges and opportunities for nursing". London: RCN; Levenson, R (2007), "The Challenges of Dignity in Care - upholding the rights of the individual". London: Help the Aged; Department of Health (2006) "Dignity in Care". London: Department of Health.
[xiii] Department of Health (2006), "Safety First: A report for patients, clinicians and healthcare". London: Department of Health.
[xiv] Department of Health (2008), "High Quality Care for All - NHS Next Stage Review final report". London: Department of Health.
[xv] Francis, R (2010), "Independent Inquiry into Care Provided by Mid-Staffordshire NHS Foundation Trust January 2005 - March 2009 - Volume I; and January 2005 - March 2009 - Volume II". London: The Stationery Office.
[xvi] Bridges, J, Flatley, M, Meyer, J (2010) "Older people's and relatives' experiences in acute care settings: Systematic review and synthesis of qualitative studies". International Journal of Nursing Studies, 47: 89-107.
[xvii] Green, J, Young, J, Forster, A, Mallinder, K, Bogle, S, Lowson, K and Small, N (2005), "Effects of locality based community hospital care on independence in older people needing rehabilitation: randomised controlled trial." British Medical Journal, 331(7512): 317-322; Small, N, Green, J, Spink, J, Forster, A, Lowson, K and Young, J (2007), "The patient experience of community hospital - the process of care as a determinant of satisfaction." Journal of Evaluation in Clinical Practice, 95-101.
[xviii] Wilce, G (1988), "A Place Like Home: A radical experiment in health care." London: Bedford Square Press.
[xix] Tucker, H (2001), "Turning community hospitals into assets". Meads, G and Meads, T, "Trust in Experience". Abingdon: Radcliffe Medical Press, pp103-120.
[xx] Green, J et al (2005) op cit.
[xxi] Hine, C, Wood, VA, Taylor, S and Charny, M (1996), "Do community hospitals reduce the use of district hospital inpatient beds?" Journal of Royal Society of Medicine, 89(12): 681-687; Heaney et al (2006) op cit.
[xxii] RCGP (1983), "General Practitioner Hospitals: Report of a Working Party appointed by the Council of the Royal College of General Practitioners - Occasional Paper 23." London: Royal College of General Practitioners; RCGP (1990), "Community Hospitals: Preparing for the future - Occasional Paper 43". London: Royal College of General Practitioners and Association of GP Community Hospitals.
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