90 per cent of smaller hospitals have gaps in junior medical cover, and over 70 per cent are reliant on locum staff for acute medical consultant cover. Some trusts have services entirely reliant on locum staff. These are the salutary but, for many, unsurprising findings from a Nuffield Trust survey to be published soon.
The solution, to which many jump, is to reduce the number of hospital sites where that care is delivered. Not only, it is argued, will reconfiguration help solve the workforce problem by expanding the critical mass of doctors per site, it will improve quality and save money. One in three STPs have at least one smaller hospital under the threat of closure, and most areas have plans to reconfigure some element of hospital services.
But a recent seminar that we held on reconfiguration – looking at the lessons we can learn from the UK and abroad – should give pause for thought to those who turn to reconfiguration as their first solution to medical workforce problems.
Will reconfiguration solve the workforce problem?
First, medical staff might not move with the services. Doctors are in a sellers’ market – it is possible that reconfiguration will trigger medical staff to leave.
Second, the recruitment difficulties faced by many sites reflect broader recruitment issues – particularly in more rural and remote areas. Reconfiguration will not solve these issues unless services are moved considerable distances.
Third, while reconfiguration may make it easier to construct a 24/7 rota, it will not change the staff/patient ratio. Reconfigured services can produce sites where staff are put under intense pressure with significantly expanded workloads.
Hospital reconfiguration carries risks, and there is conflicting evidence about its benefits
There is mixed evidence on the impact of major reconfigurations on quality of care.
The consolidation of services carries risks as well as potential benefits. The volume-outcome literature (which argues the more you do, the better you are) that frequently underpins the safety argument for reconfiguration and argues that bigger is better, only applies to a very small percentage of emergency department attendances.
The withdrawal of hospital services from an area means longer travel times and significantly increases the workload of local ambulance services, with considerable associated cost. The reduced access to services has a disproportionate effect on older and poorer patients.
A recent review of the impact of reconfiguration on emergency care systems in Ireland has so far found nothing to suggest reconfiguration has improved outcomes. Evidence that it brings financial savings is almost entirely lacking too.
What are some of the alternative workforce solutions?
Avoid service fragmentation and establish an acute care hub
Hospitals manage acutely ill patients in an increasing number of separate, distinct areas, including the emergency department, ambulatory care unit, medical assessment unit and frailty unit. Each area requires separate medical and nursing cover.
The Royal College of Physicians recommends that hospitals establish an acute care hub that brings together all these areas. This is more efficient, as staff can be deployed flexibly across the hub, and increases senior input.
Provide access to specialist expertise through a network-based approach, supported by new technology
A major challenge for the smaller hospital is accessing the necessary specialist expertise for infrequent but potential life-threatening clinical cases.
A good example is the capacity to undertake an emergency scope for someone with a gastrointestinal bleed – an event that is likely to happen out of hours only once or twice a month in a smaller hospital. But good clinical networks, underpinned by rapid local assessment and diagnosis, and reliable transfer arrangements can provide a safe, cost-effective solution.
Adopt ambitious new approaches to medical and non-medical training
A radical refocus of medical training in Northern Ontario towards community settings has practically eliminated high levels of doctor vacancies in those areas. Students’ exposure to community settings not only encourages them to work there, but gives them experience of a wide range of health issues that reflect broader population health needs.
A two-year postgraduate programme can deliver a new nurse or equip a senior nurse to undertake an advanced practice role. Training and credentialing existing clinical staff can help fill skills gaps – all in a much shorter timeframe than even the fastest paced service reconfiguration.
There is a compelling business case for investment and innovation in training and ways of working, particularly if set against the current costs of agency staff and the potential costs of reconfiguration.
There are workforce solutions to our workforce problems – reconfiguration need not be our first port of call.
Imison C (2018) "Hospital reconfiguration: if workforce is the problem, why is workforce not the solution?", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/hospital-reconfiguration-if-workforce-is-the-problem-why-is-workforce-not-the-solution