First major study on community hospitals argues policy makers need to focus on social value to patients and communities

Researchers at the University of Birmingham’s Health Services Management Centre & Third Sector Research Centre in collaboration with the Community Hospitals Association (CHA) and Crystal Blue Consulting led one of the first major studies to explore the role of community hospitals, patient experience and the relationship which community hospitals have with their local community.

Although previous studies have suggested a link between the history of place, hospital, health and community, this study is the first to demonstrate these findings across multiple community hospitals in England.

The university’s commitment to patient and public involvement ensured that key stakeholders, including the Community Hospital Association, staff, patients, carers and the public, were involved in the design and delivery of this study.

The study funded by the National Institute for Health Research (NIHR) found:

Q1: What is a community hospital?

• National mapping identified 296 community hospitals (with beds) in England in 2015 (although detailed data were available for 267). Analysis of the 267 sites showed that community hospitals with beds typically were:

o   small with less than 30 beds

o   in rural  areas

o   led by general practitioners (GPs), in-house doctors and nurses provided step-down and step-up in-patient care for frail, older inpatients and a range of additional local, intermediate and generalist care services.

• They were also: historically embedded within and valued by their local communities, had complex models of ownership and provision and provided a valued, relational model of care based on integrated, multidisciplinary working.
• However this picture was constantly evolving in response to external demands. Significant recent changes included a reduction in inpatient beds, withdrawal of GPs, increased ‘step-down’ referrals from acute hospitals and increased level of care needed by patients.

 Q2: How do patients and carers experience community hospitals?

• People said that it felt different being a patient in a community hospital compared with elsewhere: it felt more like home because of its location and familiarity, environment and atmosphere, and the relationships between staff, patients, families and the community. People described a holistic and personalised approach to care, which was particularly valued as admission to hospital was often associated with difficult changes in personal circumstances. 

• Relationships between patients, their families, staff and community members and relationships between all these people and their environments were an intrinsic factor in people’s rehabilitation and recovery.

• When considered together, four particular aspects of care (functional, interpersonal, social and psychological) point to community hospitals as providing a relational (human, caring, attentive) model of care. This relational model of care was facilitated through:

o   a closeness to home and community, for patients, their families and staff;

o   the co-location and integration of a range of intermediate, generalist and personalised services;

o   the small size, familiar and homely environment of community hospitals; and their connection to, and integration with, the local community.

• However, these elements were all in flux; for example, functional aspects of patient experience were changing as patients were drawn from an increasingly wide geographical area, whereas, in other cases, the interpersonal aspects were challenged by pressures on staff, recruitment challenges and growing pressures on beds.

Q3: What does the community do for its community hospital and what does the community hospital do for its community?

• Communities support their hospitals in four key ways:

o   Giving time (volunteering) 

o   Raising money (financial donations and fundraising)

o   Providing services (services and activities within and outside the hospitals, for patients, their families or for the hospital in general)

o  Giving voice (considerable frustration was expressed about the ability of communities and individuals to influence strategic decisions in the NHS).

• The voluntary support that communities provide to their community hospitals adds to and is, an integral part of the ‘social value’ of community hospitals.
•  However, there are considerable variations between the different hospitals studied (levels and forms of voluntary support between community hospitals); within hospitals (regular, active volunteer involvement); and overtime (voluntary income, membership and general patterns of engagement are reducing).

The study concluded community hospitals represented a significant community asset, with a strong sense of community ownership.  Their provision of local, accessible health and social care services has significance, particularly in more isolated rural communities.

Through addressing the three study questions, new understandings of community hospitals have been provided. These understandings take us beyond the individual questions of what a community hospital is and how it is experienced, supported and valued (as outlined above), to new understandings of what community hospitals mean.

Community hospitals mean more to communities (inclusive of patients, carers, staff, volunteers and other local residents) than simply a place to receive health care. The study highlighted three particular inter-related meanings:

1. Local, integrated intermediate and generalist care that brings together primary, community and secondary health care, and health and social care, statutory, voluntary and community provision in one accessible location.

2. An embedded, relational model of care that stems from the embeddedness of community hospitals, not only to their local health-care systems, but more fundamentally to the histories, geographies and social relations of the communities in which they are based.

3. A deep sense of reassurance that comes from the physical proximity and presence of the hospital, but also from the different forms of interaction with it and the sense of ownership that this inspires

Jon Glasby, Professor of Health and Social Care and Head of School of Social Policy at the University of Birmingham said:  

"Our study shows how community hospitals are contributing to 'community value' through important functions within the communities in which they serve. Their provision of local, accessible, integrated health and social care services has an important practical and symbolic significance, particularly in more isolated rural communities. When difficult decisions are made about funding and future service provision for community hospitals therefore, policy makers need to take into account a broader notion of value, focusing equally on the ‘value’ to patients and communities as on the money ." 

Dr Helen Tucker, President of the CHA who's organisation were part of this study says:

“The CHA views the study and the report as an important contribution to the planning and management of health care services, offering new knowledge and evidence on the role that community hospitals have to play across the whole health and care system, and also within their communities.  It is hoped that the evidence will be of value to all concerned with community hospitals, and in particular commissioners, providers, patients and their communities. “

The study of community hospitals was a multi-methods study, with three phases. Phase one involved national mapping, and construction of a new database of community hospitals through dataset reconciliation and verification. Phase two involved nine case studies, including interviews and focus groups with patients, carers, staff, volunteers, community stakeholders and managers and commissioners. Phase three involved analysis of Charity Commission data on voluntary support.

The report will be available to download from here.

For more information or interviews, please contact: Hasan Salim Patel, Communications Manager (Arts, Law and Social Sciences), on +44 (0) 121 415 8134 or contact the press office out of hours on +44 (0) 7789 921 165

• The lead authors of this study include Deborah Davidson, Angela Ellis Paine, Jon Glasby and John Mohan at the University of Birmingham’s Health Services Management Centre (HSMC) and Third Sector Research Centre, together with other colleagues from the University of Birmingham, the Community Hospitals Association and Crystal Blue Consulting.
• The Health Services Management Centre (HSMC) at the University of Birmingham is one of the UK's foremost centres for research, evaluation, teaching and professional development for health and social care organisations. HSMC has established a unique reputation as a 'critical friend' of the healthcare community and strives constantly to bridge the gap between research and practice.
• The Third Sector Research Centre (TSRC) aims to enhance the knowledge of the third sector through independent and critical research, giving us a better understanding of the value of the sector and how this can be maximised.
• The University of Birmingham is ranked amongst the world’s top 100 institutions, its work brings people from across the world to Birmingham, including researchers and teachers and more than 5,000 international students from over 150 countries.

The National Institute for Health Research (NIHR) is the nation's largest funder of health and care research.

The NIHR:

• Funds, supports and delivers high quality research that benefits the NHS, public health and social care.
• Engages and involves patients, carers and the public in order to improve the reach, quality and impact of research.
• Attracts, trains and supports the best researchers to tackle the complex health and care challenges of the future.
• Invests in world-class infrastructure and a skilled delivery workforce to translate discoveries into improved treatments and services.
• Partners with other public funders, charities and industry to maximise the value of research to patients and the economy.

The NIHR was established in 2006 to improve the health and wealth of the nation through research, and is funded by the Department of Health and Social Care. In addition to its national role, the NIHR commissions applied health research to benefit the poorest people in low- and middle-income countries, using Official Development Assistance funding. This work uses data provided by patients and collected by the NHS as part of their care and support and would not have been possible without access to this data. The NIHR recognises and values the role of patient data, securely accessed and stored, both in underpinning and leading to improvements in research and care.