This blog marks the first in new series of comment pieces from our New Cavendish Group members. In this piece, Matt Gaskins, a researcher and project manager for the group, outlines some of the challenges smaller hospitals are facing and offers his prognosis for the future.
Until quite recently, small hospitals in England were often viewed more as a problem than an opportunity.
A few months after the 2013 Francis report on the failings at Mid Staffordshire NHS Foundation Trust,news broke that Monitor would undertake a study to explore the viability of other small hospitals across the country. This understandably led to a great deal of anxiety among clinicians and managers at these organisations, who feared that they would be caught up in the drive towards greater centralisation of services.
This changed in October 2013 with the announcement that Simon Stevens would be appointed as Chief Executive of NHS England. In one of his first interviews with the press, Stevens sent a strong signal that small acute providers not only have their place in the English NHS, but that they should play a bigger, albeit different, role, particularly in the care of older patients. The fixation with centralisation in some parts of the system had been challenged, allaying the concerns of experts that reconfiguration might be extended inappropriately beyond areas such as stroke or major trauma.
Amid this shift in national policy focus, the Nuffield Trust set up the New Cavendish Group, a learning network to support smaller hospitals with the unique challenges they face. The group brings together 33 chief executives of these organisations, and its quarterly meetings provide an opportunity for them to share ideas and be a collective voice on the importance of small hospitals in the NHS.
In the seven meetings that have taken place since the group first met in October 2014, we have discussed tariff and pricing issues for small hospitals. Chief executives and their colleagues from member trusts have shown us how they are working innovatively with primary care in their communities. We have discussed the future provision of radiology services, the role of the generalist in acute and geriatric medicine, and how member trusts are using technology to improve patient care.
Members have told us about a range of workforce challenges, including the difficulties of attracting staff to rural and remote locations. And we have had regular updates from the Vanguard sites among the group about how they are addressing these challenges – including new and imaginative ways to staff their hospitals and extend what they do outside their organisations in the community. An important focus for the members of the New Cavendish Group is to find and share solutions.
So what does the landscape look like for smaller hospitals 18 months on from Simon Stevens’s statement of support?
Having to do more with less
Unsurprisingly, finances are at the top of the members’ list of concerns. Small hospitals continue to carry out a disproportionate amount of lower-margin emergency work compared to larger hospitals, and have a lower share of non-tariff income from sources such as research and specialist services. As one member of the New Cavendish Group recently told me, “Standards are rightly being pushed higher to seven days with daily ward rounds and inputs from all sorts of specialists, but the income just doesn’t cover it.” There is also some concern about whether there is a clear connection between some input standards and outcomes.
Challenges and opportunities for the workforce
Members of the New Cavendish Group report critical shortages of specialists such as gastroenterologists, geriatricians, middle-grade paediatricians, interventional radiologists and middle and senior grades in emergency medicine. While these shortages are national and affect larger hospitals as well, their impact is more apparent in smaller hospitals – many of which are struggling to provide staffing cover in compliance with national standards but for relatively low numbers of patients. This is exacerbated by a reduced number of trainees. With little slack in the system, it is very difficult for smaller hospitals to run compliant rotas. And of course for nurses, there is a serious national shortage.
Having said that, necessity is the mother of invention, and smaller hospitals have been innovative. Because of longstanding issues with staffing, small district general hospitals have had to plough on with alternative solutions and are already well down the road of developing enhanced and advanced roles. These include physician associates, but also advanced nurse practitioners and advanced care practitioners, who are working in some cases interchangeably with junior doctors in settings such as urgent care or orthopaedics.
Coordinating competing interests
Thirdly, aligning the interests of providers (and commissioners) in each health and care system is a real challenge for all hospitals, whether large or small, given that financial incentives and regulation have made competition rather than collaboration the rule. One member mentioned to me last week, “Transformation is urgently needed, but that requires all stakeholders to have a strategic view that is aligned – but they are not always aligned or strategic. They can be transactional and regressive.”
Whether NHS England’s Sustainability and Transformation Plans will lead to more progress in this regard than, say, the Integrated Care Pioneers, remains to be seen. However, as one of the member CEOs noted recently, “One advantage of being a small hospital is that we are more flexible and generally not seen as aggressive by other stakeholders, which means there is a greater willingness to work together and explore new models of care and integrate the workforce.”
At the core of all of this is the concern about the quality of patient care and how to maintain it. Another member of the group pointed out that “it isn’t just about keeping the lights on and the services going, but whether the quality is at a high enough standard. We are under such pressure to maintain quality”.
What's the prognosis?
The Nuffield Trust will be bringing together leaders, thinkers and practitioners on 12 July 2016 to discuss the viability of smaller hospitals at a debate with the NHS Confederation. And of course the New Cavendish Group will continue to tackle these and other issues in its quarterly meetings.
A few years ago, the fate of smaller hospitals looked uncertain. With the landscape for all NHS providers looking tougher than ever, this is still the case today. But there is reason to be hopeful: since our first meeting of the New Cavendish Group in 2014, we have seen numerous examples of smaller hospitals innovating, experimenting and finding new ways to meet the challenges they are facing. The first 18 months have been promising. But with hospitals facing huge deficits, and NHS England’s Sustainability and Transformation Plans raising yet more expectations that smaller hospitals will have to meet, the next 18 months may present the greatest test of all.
Gaskins M (2016) ‘Has the tide turned for small hospitals?’. Nuffield Trust comment, 9 May 2016. https://www.nuffieldtrust.org.uk/news-item/has-the-tide-turned-for-small-hospitals