Paul Mears is Chief Executive of Yeovil District Hospital and one of the founding members of the New Cavendish Group, a learning network to support small and medium-sized hospital trusts. We sat down with Paul to talk about the viability of small hospitals, the challenges they face and what he thinks some of the solutions might be.
When it comes to hospitals, there is a common view that 'size matters'. Given the dearth of evidence behind that, at least beyond areas such as stroke or major trauma, what are your views?
As you say, the traditional view is that the quality of outcomes will depend on the size of the service, the volume of certain procedures performed and the number of available consultants. This means that recording outcomes and collating clinical evidence is vital in avoiding inappropriate closure of small but well-functioning units. For example, when we were reviewing stroke services in Somerset, the outcomes for outpatients in Yeovil were actually as good as those at the neighbouring larger trust. It's being able to produce evidence that is crucial.
Similarly, it would help to improve relationships and service developments in some cases if commissioners or other system leaders who are seeking to reconfigure services could provide stronger clinical evidence to support their objectives, rather than falling back upon the historical notion of 'small equals unsustainable'. There are always difficult conversations to be had, particularly given the current financial climate, but they can be greatly facilitated if both sides provide the evidence.
Traditionally, the areas in the spotlight when people talk about the viability of small hospitals are emergency surgery, A&E, paediatrics and maternity. Making changes to such services is very contentious, particularly if they are rushed through without proper consideration of how they are going to be managed politically and publicly.
It's important to note that the solution doesn't always have to involve a massive relocation of the service; it's always going to be preferable to first try and find a different way of achieving sustainability through networking and collaboration.
What are the biggest problems for small hospitals?
One of the most fundamental issues for smaller hospitals is maintaining financial sustainability. Historically, top-ups to the tariff have been offered to large teaching hospitals in recognition of the specialist element of their work. But there are certainly members of the New Cavendish Group who feel that these arrangements short-change small hospitals. In the future, I think there needs to be a premium for smaller hospitals to recognise the cost that comes with running sustainable services for more rural local geographies.
For example, in Morecambe Bay they’ve managed to negotiate a variation to the A&E tariff using so-called Local Price Modifications to recognise the particular challenges posed by their geography.
In some hospitals, we're being paid the same as a large teaching hospital to run a full maternity service. Despite our lower income, our cost base is similar. There needs to be more acknowledgement of that.
How do you think smaller hospitals might become more sustainable?
The need for smaller organisations to work in new ways – for their very survival – is actually a huge opportunity. I would argue that smaller hospitals have had to be creative for some time, and are now often better prepared culturally than many larger organisations to implement radical change. Despite all the challenges we are facing, there are currently opportunities for smaller hospitals to position themselves at the forefront of some of these developments.
One of the ways this might happen is through collaboration. Typically, collaboration between trusts in the UK, particularly through mergers and chains, have had negative connotations. People assume it means a small hospital being taken over by a larger one. But it doesn't necessarily have to be like that. Groups of smaller hospitals that aren't in close proximity geographically can still work together in a more joined-up way – and technology can enable that.
We are starting to explore some of these ideas in our own trust with telemedicine, which allows us to link up with neighbouring trusts. For example, with stroke medicine, we share a rota with our neighbours – a large trust – in Taunton, Somerset. Part of the way we do that is by having telemedicine link between the two, so if a consultant isn’t available on site, the senior nursing team can still access remote advice and support from a consultant.
Different staffing models came up a lot in our last New Cavendish Group meeting in March. What do you think are the big opportunities there?
Making clinical jobs in small hospitals of interest to clinicians is a particular challenge, since people are traditionally more attracted to roles in large teaching hospitals, within teams in a particular specialty. A big part of the solution is to give people the opportunity to think about creating jobs that are more varied and to experiment with different forms. For instance, even if a clinician is predominantly based in a small hospital, this doesn’t mean that he or she can’t also train and undertake clinical work in a larger centre.
Another big issue is how you move toward a more generalist model in hospital care for small hospitals. Local hospitals are potentially the places that can lead on developing some of those models. But of course you have the challenge of developing roles that aren’t currently in existence. A solution to this might be that a consultant in acute medicine could start to work in a more generalist capacity, but ultimately acute medicine, as a specialty in its own right, is still in its early stages.
Current training programmes aren’t creating general surgeons. Many hospitals have general surgeons who are approaching retirement, and there is definitely a concern that it will be difficult to recruit to those types of roles in the short to mid-term.
It’s not just about doctors, though. We also need to focus on how we can use other health professionals in a different way – the nurses, therapists, paramedics and other staff. Smaller hospitals have made more progress than many other organisations in finding creative solutions to workforce challenges because they have had to, as Matt Gaskins pointed out in the opening blog to our New Cavendish series.
In my own organisation, nurse consultants and others often work very closely with physicians in certain specialties, taking on tasks that perhaps would traditionally be carried out by a doctor. I know there are other trusts, such as Airedale, that have people such as paramedics working alongside their A&E teams or physiotherapists who can start to do extended-scope work for orthopaedic patients. It is not about filling the gaps, or about nurses or paramedics doing the work that doctors should be doing. It’s about making the most of each health professional’s education and training in a way that is safe and evidence-based.
The reality is that even though the colleges are changing, these changes aren’t going to produce the newly skilled-up clinicians for another 10 years. So, ultimately, we’re going to have to find creative ways of developing and succeeding with what we’ve got.
On 12 July we are hosting our second debate in our series with the NHS Confederation, which will be on the subject of smaller hospitals. The event, Daring to ask: is there a future for smaller hospitals in the NHS? will be live streamed and can be followed on Twitter with #NHSdaringtoask.
Mears P (2016) ‘Are smaller hospitals sustainable?’. Nuffield Trust comment, 21 June 2016. https://www.nuffieldtrust.org.uk/news-item/are-smaller-hospitals-sustainable