The rising number of patients who are older and/or with multiple conditions is considered one of the most pressing problems facing the NHS. It is argued that current models of hospital care, which are based around specialists delivering disease-specific care, serve these patients poorly, as it is often fragmented and poorly coordinated. A revival of medical generalism, which is delivered by consultants with a broader knowledge of multiple conditions and focuses on coordinating holistic, patient-focused care, has been suggested as a way of providing better and more cost-effective care.
In order to test this hypothesis, we looked at the models of care of medical generalism and specialism in smaller hospitals (with an operating revenue of under £300 million a year) in a large mixed-methods study, involving 1.9 million care episodes in 50 hospitals. We also sought the views of hundreds of staff and patients on the strengths and weakness of the models through 11 case study visits, interviews, focus groups and an online survey.
The headline conclusion was that while the case-mix of smaller hospitals was dominated by presentations that were amenable to generalist approaches to care, there was no evidence that any model of care produced better outcomes for patients. However, the study did provide a wealth of data on how models of care are conceived and then executed. And here are a few key lessons on how organisations could make care better for patients and staff alike.
1. Smaller hospitals ARE different
Our smaller hospital cohort was very varied – ranging from hospitals with only 250 beds in very rural locations through to hospitals with over 800 beds in urban areas. However, there were markedly more similarities than differences. Moreover, smaller hospitals viewed themselves as being entirely distinct from their large, urban, teaching counterparts. It was also clear that solutions developed in larger hospitals were not fit for purpose in their smaller counterparts. While the term ‘district general hospital’ was abandoned with the introduction of foundation trusts, it needs to be acknowledged that smaller hospitals are different and require different approaches and policy solutions.
2. Models should be designed to meet patient need
This might seem obvious but we found that models of care were rarely the product of deliberate design. Instead, they usually arose in response to external pressures (such as an edict from NHSE/I) and were hastily implemented using the available resources (staff, estate, money). This meant that models of care rarely matched local patient need, which was consistent and predictable in most organisations. Basing systems on analysis of local need would likely lead to more coherent systems of care and better outcomes in the longer term.
3. Models should be designed from the front end all the way through to the back door
Because of the way models of care arise, little attention is paid to how the patient passes through the system and how each transfer of care impacts on the patient and other parts of the hospital. Understanding the whole system and smoothing patient transfers should improve patient flow and get patients to the right place much faster.
4. Models should be designed for ‘bad’ days, not for ‘good’ ones
Virtually every hospital admitted major gaps between how their models of care were meant to work and how they actually worked. All models broke down in the face of internal and external pressures on a regular basis, leading to work arounds. Designing systems for high periods of demand would lead to greater resilience and mitigate against the annual problem of winter pressures.
5. ‘Streaming’ versus the ‘acute hub’
Many hospitals are using ‘streaming’ models of care, where patients are moved out of emergency departments to one of several parallel places for their initial assessment and care (such as an acute medical unit, acute surgical unit or frailty unit). While this can have advantages, the resulting highly complex flows can be difficult to manage, particularly when units are geographically dispersed throughout the hospital site. In some cases, spreading staff over lots of different units exacerbated shortages and fragmented capacity, thereby reducing flexibility.
Others were moving to an ‘acute hub’ model, where all the acute specialties were effectively co-located with enhanced access to diagnostics and other support services. While this appeared effective, it frequently required major capital spend to build appropriate spaces. Given that both models had substantial advantages and drawbacks, neither could be considered a ‘magic bullet’ to solve the problems of overcrowded emergency departments.
6. Continuity of care matters
Discontinuity of care was the norm, with even patients with very short lengths of stay experiencing multiple changes of consultant. This was most pronounced on wards which operated ‘consultant of the day’ models of care. We found that each change of team added two days to the length of stay. More importantly, staff drew direct lines between revolving doors of consultants, staff disengagement and poor patient care. A focus on improving continuity of care would likely shorten length of stay, improve care and lead to greater staff satisfaction.
7. Improving pathways rather than models of care
Pathways of care varied markedly both between and within organisations, resulting in noticeable differences in lengths of stay even for patients with the same diagnosis and similar characteristics. This implies that focusing on pathways of care for specific high-volume patient groups within organisations might improve outcomes, without needing to change the overall model of care.
8. Managing consultant behaviour
Most consultants accepted that working in a smaller hospital meant that contributing to the generalist work was inevitable (if not enjoyable). However, we found patterns of behaviour, particularly ‘flight from the front door’ (refusing to participate in the acute take) and ‘fortressing’ (limiting service provision, through mechanisms such as capping/quotas or setting up parallel rosters for emergencies which occur only rarely). In all instances, consultants were actively seeking to limit their exposure to inpatient care and regulate their own workloads.
These behaviours were viewed as highly destabilising and often resulted in artificial workforce shortages and discontent among the consultant body. Hospitals that were able to manage these behaviours, and where work was distributed in ways that were transparent and equitable, were viewed as being more desirable places to work.
9. Getting training right
We found that older consultants, particularly those who had not followed conventional training pathways, were more comfortable with patients who were older and/or had multiple conditions. While younger consultants were happy managing an acute take, they often felt under-prepared for caring for these patients on the wards. Senior trainees who had had good experiences of training in smaller organisations managing many different types of patients were more likely to return to a smaller hospital. This suggests that focusing on the training of junior and middle grade doctors in the care of older and co-morbid patients will pay dividends for smaller hospitals in the longer term.
10. It starts at the top
Although we did not use any measures of cultural environment, we still found that organisations with stable leadership and which had invested heavily in programmes to improve culture and cooperation were more likely to have coherent, well-structured models of care and happier staff. Such organisations also tended to have a strong sense of mission and shared purpose in caring for their local communities.
11. The problem of ‘system shock’
Many smaller hospitals viewed themselves as being under genuine existential threat – either closure or major merger. The lack of resources tended to make them more vulnerable to both internal and external ‘system shocks’ (an organisation-wide event that detracts from day-to-day operations). While the provision of additional funding (both annual and capital) would be a major boost, the calming of the external environment and allowing smaller hospitals to focus on patient care would also make a major difference.
12. Patients don’t care about models of care
While patients exhibited an overall preference for specialist care, most were realistic about what a smaller hospital was able to provide. As such, the model was much less important than patients being reassured that their local hospital was able to meet their needs and that the overall quality of care was of a high standard.
Research into action
These lessons point to the need for a much more deliberate approach to the design of the whole system of care and a move away from the relentless focus on the front door of the hospital. It also points to locally developed solutions using evidence-based design principles rather than the adoption of national, one-size-fits-all models. Continuity, generalist skills and other aspects of medicine that have often been undermined over the years prove to still be important. The goal should be to provide local high-quality services that meet the needs of local patients, with appropriate funding and policies to enable smaller hospitals to do just that.
Vaughan L (2021) “It’s not just about the front door of the hospital: lessons from the medical generalism in smaller hospitals study”, Nuffield Trust comment.