I have heard the word ‘hospitalist’ being bandied about quite a lot recently, with hospitalists being touted as the cure for problems with smaller and large hospitals alike. This is likely to be down to the fact that Robert Wachter – Professor of Medicine at the University of California, San Francisco and leading light of the US hospitalist movement – was in town. Professor Wachter has been brought over to advise NHS England on the implementation of digital technologies in health care, following the recent publication of a book on the subject.
However, his brains are also being picked for solutions to the growing crisis in acute and general medicine brought about by the increasing numbers of older and more complex patients needing unscheduled medical admissions. The Nuffield Trust met with Professor Wachter, along with a number of key NHS leaders, thinkers and managers, and heard first-hand his account of the hospitalist model. While there was considerable enthusiasm for the model in the room, the conclusion was that any transfer of lessons from the model to the English context would require careful consideration.
What is the hospitalist model of care?
Traditionally, the separation of primary and secondary care has been much less clear in the United States than is the case in other countries. Although family care physicians (FCPs) provided primary care in a manner that was very similar to general practitioners, they also followed their patients into hospitals. When patients were in need of specialist input, this was given on a consultation basis, with patients remaining under the supervising care of their family physician, rather than being transferred to the specialist.
Although patients enjoyed the near-complete continuity of care, this system created a number of problems. FCPs often had little exposure to hospital medicine while training, yet they were expected to deliver complex care to unwell inpatients. Likewise, medical specialists, who received virtually all of their training in the hospital setting, had little to do with inpatient care. FCPs tended to round early in the morning, leaving the wards and junior doctors unsupervised during the day. The longer lengths of stay and gaps in patient safety that resulted led to the creation of a new group of doctors: the hospitalists. These doctors were based only on the hospital wards, concentrating solely on the care of the acutely ill hospitalised patient.
Hospitalist medicine became the fastest-growing medical specialty in history and is now the dominant specialty in the US, with over 50,000 hospitalists providing care in almost every hospital in the United States.
What were the success factors for hospitalist medicine?
1. Money – and lots of it
Professor Wachter made no bones about the fact that the chief factor in the success of the hospitalist movement was the money. As the introduction of a hospitalist programme results in a 15 per cent reduction in length of stay and keeps the hospital lawyers happy, chief financial officers consider the US$450,000 in wages and benefits for each hospitalist to be money well spent. While FCPs initially bemoaned the drop in income, most found that the loss of a handful of hospital patients could be compensated for by less travel and more time in the office seeing patients.
2. Little additional workforce training was required
The fundamental misalignments in the US system between type of training and subsequent place of practice of doctors were a profound driver of the movement. Internal physicians are hospital-trained generalists, similar to general physicians, but as non-procedural medical specialties they tend to be poorly remunerated. Many had moved into family care practices – work which they had not trained for and clearly found unsatisfying. It was this group of doctors that subsequently made up about 90 per cent of the hospitalist workforce. Having doctors who required no additional training allowed for very rapid expansion of the field – far beyond what would have been possible had workforce demands required the training of new doctors.
3. It piggy-backed off the quality agenda
The hospitalist movement was quick to strategically align itself with the quality and safety agenda that followed from the ‘To Err is Human’ and ‘Crossing the Quality Chasm’ reports, which identified major harm to hospitalised patients and advocated almost complete re-engineering of the US health care system. This allowed hospitalist medicine to be branded around improvement, and reassured patients that the advantages of having a hospitalist provide inpatient care outweighed any problems caused by no longer having perfectly continuous care provided by their GPs.
4. The market was crucial in determining the final model
The independence of hospitals allowed for large-scale experimentation with the model. In organisations where the offer benefited patients, doctors, lawyers and the chief financial officer, the model thrived. Where the offer was wrong, hospitalist programmes simply collapsed, often in the space of months. This Darwinian environment allowed for very rapid learning about what was essential to success and what was not.
Considerations for the English health system
The financial reality of the English system will constrain moves to a hospitalist model
Professor Wachter estimated that the costs of implementing the hospitalist system across the United States were in the region of US$20 billion. The introduction of hospitalist services in individual hospitals also required substantial upfront investment, for which most hospitals did not see a return for 5–7 years.
There are just not enough doctors in England
In Professor Wachter’s 600-bed hospital, 70 hospitalists provide 35 full-time equivalent (FTE) of clinical care for 150 beds and input into the care of another 50 patients. Contrast that with a similarly sized hospital in England, which typically would have 40 medical consultants, providing 25 FTE of inpatient care.
The marked difference in medical manpower relates to the fact that the number of patients clinicians can provide care for in the United States is capped, with a hospitalist typically having a ‘census’ of only 12–16 patients. In the English system, consultants tend to care for a whole ward or unit with anywhere between 25 and 50 beds. A move to a hospitalist model would require many more doctors and, given that at least half of all hospital medical consultant posts advertised in England go unfilled, there is just not enough medical manpower to support such a change.
An English hospitalist model would require a major reconfiguration
As US inpatients were usually cared for by their FCPs, most hospital wards fell into the category of ‘general medical’, with very few wards providing highly specialised care. The introduction of hospitalists, then, usually meant swapping one type of consultant for another, while keeping almost everything else, from nursing staff to ward layout, intact. This is not the case in England, where there has been a strong movement towards centralised, specialist inpatient care. The introduction of hospitalism would require yet more service reconfiguration and expense.
Finding roles that motivate the workforce can be powerful
Doctors value jobs that provide them with a high degree of autonomy over their working lives. Although hospitalist jobs may appear superficially unattractive, involving plenty of night and weekend work, most hospitalist programmes go to some lengths to provide doctors with a good deal of choice over when and how they will work. For example, doctors prepared to work more nights have the first pick of the more attractive non-clinical duties, such as education, or may have more days off, while other doctors preferring steady 9 to 5 clinical work do this at the expense of non-clinical duties. This ability to tailor job plans to individual intellectual interests and lifestyle preferences was a key motivating factor in getting internal physicians to abandon 9 to 5 jobs as FCPs and move into the hospital setting.
Professor Wachter underlined that the key lesson for English health care lies not in hospitalism as a model of care, but in the process of how it became so successful. There was a very clear assessment of problems at system level and rapid movement to align hospitalist services with other national agendas, making the introduction of hospitalist services to the advantage of all players in the system. In England, there still has not, I believe, been a real systematic reckoning of the multiple factors responsible for current deficiencies in hospital care. The Nuffield Trust has embarked on a number of projects to unpick what exactly is going on in hospitals and to provide the evidence for future change.
But perhaps the most important lesson was that the introduction of hospitalists was neither quick nor easy – it has taken 20 years of leadership, planning and investment for the benefits to patients, staff and hospitals to be fully realised. A sharp lesson indeed.