Changes to staffing patterns at A&E could improve viability of smaller hospitals, research suggests

Improving A&E triage processes, encouraging groups of clinicians to pool their capacity at the hospital ‘front door’ and ending the practice of separating out services like ambulatory care units could be essential measures to shore up smaller hospitals, researchers argue today.

These recommendations come in a new Nuffield Trust report looking at the ways in which hospitals serving between 140,000 and 300,000 people run medical services for acutely ill patients.

It finds that smaller hospitals are heavily reliant on locums and have been hamstrung by a trend to “carve out” services for different types of patients. While this may be appropriate in a large hospital setting, in small hospitals it stretches already meagre staffing levels. This has meant that many are struggling to deploy staff effectively across their sites and provide cover for emergency and acute medical services, raising serious questions about their viability.

Adopting national recommendations like minimum staffing levels and specialised units for different types of patients (such as ambulatory care or frailty units) has further exacerbated staffing problems in many cases, meaning patients can be unnecessarily passed between multiple consultants and teams. 

The Nuffield Trust’s analysis, which was commissioned by NHS England, forms part of an in-depth look at acute medicine – the part of the hospital that cares for predominantly older adults needing emergency medical treatment beyond the A&E department.

Drawing on interviews with senior clinicians and managers; experts in Canada, Australia and New Zealand (all areas where healthcare serves particularly rural populations); a survey of 50 small hospitals in England; and a high-level literature review, the report presents a profile of smaller hospitals and explores the improvements that could be made to ensure their viability in the future.

The Nuffield Trust report says that there is no one change or approach that will work to fix the problems identified in smaller hospitals, but important changes that should be considered include:

• A new inter-disciplinary team at A&E, bringing together doctors from different specialties like geriatrics and emergency medicine, which could be essential in helping them overcome staffing gaps and meet the needs of older, frailer patients.
• Removing “carve out” models, whereby particular groups of patients are diverted into dedicated units, such as frailty or ambulatory care units. The Nuffield Trust argues that many remote hospitals have such a high proportion of admissions of frail patients that it does not make sense to separate them out.
• A clear national focus on training staff specifically for working in small and rural hospitals and a financial premium aimed at ambulances and other services working in remote areas.
• Changes to the roles and responsibilities of staff throughout the hospital, including roles where staff work under the supervision of a doctor or senior nurse - such as physicians’ associates and advanced practitioners - to provide cover and free up senior staff. 

Commenting on the analysis, Nuffield Trust Chief Executive and report author Nigel Edwards said:

“A toxic brew of chronic workforce shortages, deterioration in the staffing of key clinical services and spiralling costs is making the future for smaller hospitals very uncertain indeed.

“To tackle this, smaller hospitals need to be equipped to give more generalist care for patients. This can be achieved by slicker processes at the hospital ‘front door’ and through removing unhelpful practices that divert much-needed staff away from meeting the needs of acute medical patients.”