As a junior doctor who has had the privilege of being trained at a number of leading specialist and university teaching hospitals, I am well versed in the dogma of the centralisation of care. There is no doubt that the centralisation of major trauma, hyper acute stroke and serious heart attacks (known as STEMIs) services have all led to a remarkable improvement of survival in these most acute of conditions.
At the other end of the spectrum, we know that sending our patients with minor injuries to a major trauma centre will improve neither patient outcomes nor satisfaction. Few would disagree that the care of these patients should be managed in a minor injuries unit, smaller hospital A&E, urgent care centre or pharmacy.
In between are the A&E cases and general medical and surgical intake where there is no evidenced benefit of centralisation – we should rightly eliminate the clinical centralist arguments from the design of those services. Such cohorts of patient are best served more locally but in a manner which serves a sufficient size of population to be safe and to maximise efficiency. These services have to provide care without unwarranted variation, receive sufficient footfall to attract and retain an appropriately skilled workforce, and be affordable to the local health economy. At the same time they must work within a network of services enabling them to escalate to specialist care if required.
It is these services that were at the heart of our seminar on an exploratory study by the Nuffield Trust entitled, “Models of Generalist and Specialist Care in Smaller Acute Hospitals”. Many themes were discussed, and with leading clinicians and academics we attempted to unpack what is the best model of care for smaller hospitals.
The right kind of doctors
Although it is agreed that we need more doctors, The Shape of Trainingreview of postgraduate medical education and training has made us question whether we are producing the right kind of doctors; or at least doctors with the right skills. As much as specialist surgeons or physicians with a tertiary referral practice are an important part of a network, we need to ask whether this is the best type of doctor for acute patients at a smaller hospital. These specialists have long been glamorised at medical school but their popularity can lead to difficulties in filling the general medical or surgical on-call rota. Is it time we looked at other options to meet colleagues’ professional interests whilst serving the needs of the population?
There are some ways of addressing the imbalance. For example, new job plans where colleagues are trained as generalists whilst being encouraged to carry out a specialist skill in sessions at their local specialist hospital may help. This not only improves the much beleaguered morale of the doctor unable to practise the skills refined on fellowship, but also helps protect patients from the curse of unwarranted variation and expense generated from the wrong procedure in the wrong unit. Another solution can be offering GP colleagues sessions to support generalist gaps in care. An example of this is the orthogeriatrician service supplied in partnership with GPs in Dumfries and Galloway. This not only provides much-needed medical input to frail patients, but the benefits of an improved relationship with GPs also speeds up discharge and prevents readmission. This is the kind of pragmatic solution that Getting it Right First Time – or GIRFT to its friends – are seeking to share across medical and surgical specialities.
Is our system designed for our patients?
The awkward truth is that there is often less variation in the care provided by a well-trained generalist compared to a specialist who may be tempted to more frequently depart from national guidance. The other elephant in the room is that the typical patient we now see is older than 75 years and has more than four co-morbidities, and if they attend a specialist clinic for every complaint they will barely ever leave the hospital outpatient department. Of course there are certain conditions which need specialist input but many of these patients would be grateful for fewer trips to the hospital. The truth is that our hospital system was designed for patients with a single pathology, which is no longer the population they serve.
With a shortage of geriatricians, do we need to consider running joint clinics of related specialities? This would give specialists the opportunity to share advice within one clinic; which will not only save patient time but will allow colleagues to learn from each other and reduce the additional referrals.
Another part of the solution could be to adopt an integrated urgent care model as proposed by the Review of Urgent and Emergency Care. This channel shift has been designed to drive efficiency in the system so the right patient is seen by the right health care professional at the right time whilst promoting self-care. It attempts to overcome the default in the NHS that when we cannot offer what the patient needs, we default to a higher intensity, higher cost medical setting – even when the need was not medical.
It is possible to improve this for patients and create a more sustainable and affordable system, utilising health care professionals in clinical advisory service ‘hubs’ which support 999 and 111 in conjunction with out-of-hours GP services. These hubs have access to patients’ electronic records and the ability to book appointments in urgent care centres. They have connections with GPs and dentists, can transfer patients directly to the mental health team, community pharmacist or to hospital as appropriate. Such channel shifting would expect to produce a reduction of the pressures on the system: A&E attendances, hospital admissions and 999 ambulance dispatches. Still further we will see more effective use of GPs, pharmacists, a rise in early intervention in care homes, and people being able to take more responsibility for their own health.
It is no secret that patient flow is a massive challenge to every small hospital in an NHS seeing ‘winter pressures’ all year. We are all too familiar with the congestive hospital failure when bed occupancy reaches the point that efficiency is outstripped by demand. Yet it is not surprising that we have a blockage in the system when patient flow is measured in different units along the pathway. We measure 999 and 111 call handlers in seconds, ambulance response times in minutes, A&E performance in hours, occupancy of wards in days, not to mention the discharge to social care that can take weeks – funnelling patients in, but not out of secondary care. Is it now time for a more consistent approach?
As clinicians, we hear repeatedly from patients that they would prefer care in their own homes, through services and not hospitals. With 10 per cent of patients occupying 65 per cent of the beds, we would do well to focus more on enabling people to plan and manage their long-term conditions how they know best. Many patients, likely to be at high risk of an A&E attendance followed by a prolonged hospitalisation, can be predicted. Such people often have multiple chronic conditions, mental health problems, disabilities and some require end-of-life care. If we could provide them with better support in the community with a personalised care plan to anticipate their problems, this would be a mutually beneficial step to alleviating hospital congestion.
The discussions we had at the seminar will help the Nuffield Trust’s team frame their key lines of investigation in case study hospital visits. The viability and the strength of smaller hospitals lie in how the hospital relates to and is supported by its community and the wider health economy. A further seminar later on in the project will involve people working in smaller hospitals to present and test the team’s findings.
Please note that views expressed in guest blogs on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.
Machin J (2017) 'Small acute hospitals: where generalist and specialist care models meet'. Nuffield Trust comment, 24 Jan 2017. https://www.nuffieldtrust.org.uk/news-item/small-acute-hospitals-where-generalist-and-specialist-care-models-meet