Community Hospitals Research Programme

The primary aim of this study was to provide a comprehensive analysis of the profile, characteristics, patient experience and community value of community hospitals. There were three research questions: 

1. What is a community hospital?
2. What are patients’ and carers’ experiences of community hospitals?
3. What does the community do for its community hospital and what does the community hospital do for its community? 

Our commitment to patient and public involvement ensured that key stakeholders, including the Community Hospital Association (CHA), staff, patients, carers and the public, were involved in the design and delivery of this study. We are very grateful for the involvement and contribution of patients and family carers, hospital staff and volunteers, managers from Trusts and commissioning groups, and members from the nine local communities.

What is a community hospital?

Community hospitals mean more to communities (inclusive of patients, carers, staff, volunteers and other local residents) than simply a place to receive health care. 

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

• were small – 70% of community hospitals had ≤ 30 beds
• were rural – 78% were based in rural or significantly rural areas
• were led by general practitioners (GPs), in-house doctors and nurses – historically GPs have been an integral part of community hospital provision and their involvement remains significant, but it has reduced, whereas the in-house employment of doctors has grown; in practice, most community hospitals are nurse led
• were without 27/4 medical cover – community hospitals do not have 24/7 on-site medical cover and
• are reliant on nursing staff and out-of-hours doctors outside core hours
• provided step-down and step-up care for frail, older inpatients
• had an average length of stay of < 30 days (median 24 days; mean 27 days)
• had a range of additional local, intermediate and generalist care services on a spectrum from primary to acute care orientations. 

Other common characteristics we identified, highlighted the ‘dynamic reality’ of community hospitals at a local level, they were also typically: 

• Historically embedded within and valued by their local communities.
• Operating with complex models of ownership and provision.
• Providing a valued, relational model of care.
• Based on integrated, multidisciplinary working.
• Constantly evolving in response to external demands. Significant recent developments include a reduction in inpatient beds, withdrawal of GPs, a shift towards step-down provision and a growing acuity of patients.

Professor Jon Glasby provides an overview of the study of Community Hospitals in this short video.

How do patients and carers experience community hospitals?

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.

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. 

Patients and carers particularly valued four dimensions of community hospitals:

1. Environmental and functional features of community hospitals such as their locations, accessibility, surroundings, interiors, food and atmosphere.
2. Interpersonal aspects of care, such as relationships between staff, patients and family carers.  Patients described warm and welcoming staff, being looked after personally with sensitivity and respect, staff (and volunteers) spending time with them, being listened to, keeping their spirits up and time taken to care for the whole person.
3. Social aspects of patient experience included the importance of having family and friends close by so that they could be visited often and the importance of the hospital being community based, thereby increasing the chance of meeting familiar faces and being known, and of maintaining (a social) life rather than pausing it.
4. Psychological aspects of patient experience included feeling less anonymous and frightened, feeling more confident and hopeful, while also coming to terms with loss and change.  Although community hospitals were generally seen to build patients’ confidence and physical health, a greater focus on psychological, emotional and mental health was identified as needed.

But context and flux affects patient experience…

These elements were all subject to context and were 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.

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

What does the community do for its community hospital?

Communities support their local hospitals in four key ways:

1. Giving time – community hospitals, identified as having a League of Friends (or equivalent) registered with the Charity Commission, involve 24 volunteers on average, suggesting the involvement of 5880 volunteers across the 245 community hospitals. This is estimated to equate to between 1.4 and 2.5 full-time equivalent personnel per hospital, at a national value of between £3.8M and £6.9M. Volunteers were drawn predominantly from older age groups, raising concerns about future sustainability. Limits to the involvement of volunteers included a perceived lack of investment in their recruitment, co-ordination and support beyond that provided by the League of Friends or individual hospital staff. 

2. Raising money – in 2014, community hospital Leagues of Friends generated an average income of £45,387 (median £15,632). Two-fifths of all income to Leagues of Friends came from legacies. There was considerable variation in levels of income across community hospitals that could not be explained solely by levels of deprivation but instead appear to be influenced by a range of community- and hospital-level factors. Average levels of income also vary over time: since 1995 the charitable income of Leagues of Friends has declined by an average of £901 a year. 

3. Providing services – beyond the service delivery roles of individual volunteers and Leagues of Friends, various voluntary and community groups also contribute to community hospitals through the provision of a wide range of services and activities both within and outside the hospitals. 

4. Giving voice – despite a long history of community involvement in strategic decisions about community hospitals, the mechanisms and depth to which this happens vary considerably. There was considerable frustration expressed about the ability of communities and individuals to influence decisions, both within specific consultation exercises and on a more sustained, continuous basis. 

But variations exist….

Variations exist in the level of support that communities provide to community hospitals in the following ways:

• Between communities – this could not be explained by levels of prosperity/deprivation alone but was influenced by the history of the hospital, the local geography and the service and provider mix.
• Within communities – there was a particular dominance of older people among those who were most active in their support.
• Over time – quantitative evidence showed the dominant trend was one of decline, particularly in terms of income, although this was not raised as a particular concern among the case studies.

What does the community hospital do for its community?

Community hospitals fulfil a number of important functions within the communities in which they are based and provide significant value. They represent a significant community asset, with a strong sense of community ownership. Their provision of local, accessible health and social care services has an important practical and symbolic significance, particularly in more isolated rural communities. We found evidence that community hospitals can contribute to six distinct areas of ‘community value’: 

1. Instrumental – primarily through the provision of local, accessible and integrated intermediate health and social care services.

2. Economic – through the provision of local employment and the reduction of travel costs associated with accessing more distant health-care services.

3. Human – through the development of skills and confidence among, not just staff (and patients), but also volunteers.

4. Social – through the development of networks of interaction, trust and reciprocity, built directly through the services provided by the community hospital and indirectly through community engagement activities.

5. Cultural – through a sense of identity, belonging and civic pride for individual staff and volunteers, and across the community through a collective sense of place.

6. Symbolic – as a symbol of vitality and viability of the community, community hospitals contribute to perceptions of resilience and autonomy and as a source of security and reassurance. 

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 (akin to the concept of ‘ontological security’) 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. 

These meanings, however, vary between and within communities and can change over time. This research has highlighted the dynamic nature of community hospitals and their susceptibility to change because of both internal and external developments, which has contributed to their current diversity and, arguably, to their agility and resilience. The current demographic, economic and policy contexts are putting them under pressure and pulling them in different directions. The withdrawal of GPs, the shift towards step-down care, the delivery of services to a wider geographical area and associated increased acuity of inpatients and questions over the future of inpatient beds are particular demonstrations of those pressures. They have the potential to shift not just the characteristics, functions and patient experience of community hospitals but also their value and meaning.

The policy vacuum for community hospitals - caught between national centralising tendencies (bigger is better) and a continued rhetoric to provide care closer to home – means that the NHS has been driving through significant changes in services and costs without the evidence to make informed decisions; many community hospitals have lost beds and the future of others are under threat.

The recent ministerial announcement to stop the closure of community hospitals and a new NHS plan committing the NHS to work more closely with people and communities and understand what matters to them, indicates a re-evaluation and refocusing of health policy for rural areas and care closer to home. In this context, it is imperative that community hospitals, and their contribution to patients and communities, are fully understood and taken into account.

Supporting local impact: engaging with communities and professionals to use research evidence on community hospitals for community and patient benefit 

Impact activities are funded by an ESRC Impact Acceleration grant. 

Local communities are passionate about local services and see community hospitals as a vital asset, and have been active in their support of community hospitals through campaigns and petitions (e.g. facebook open groups). However they have not had access to robust evidence to support their arguments about local services, and often those most involved with community hospital campaigns primarily see their task as fundraising and volunteering, and have not had the confidence or capacity to give a voice to, and take a more proactive role in, the running of community hospital services, by engaging with local NHS providers and commissioners.

With publication of a new NHS plan in January 2019 focusing this is a unique opportunity to influence national and local policy and practice. This work builds on our original research to engage with local stakeholders involved in staffing and voluntary /community support of community hospital care in England. It also draws on the subsequent experience of the one of our case study League of Friends who were active participants in the study, and who used the opportunity to develop a different role and relationship with their local community, NHS providers and commissioners. 

Our aim is to help build the capacity and confidence of local stakeholders to engage with NHS providers and commissioners to share the study findings and enhance their awareness of the evidence and implications for policy and service delivery arising from this study. In particular to:

Work with Leagues of Friends¸ local community members, patients and carers across case study sites to understand the study findings, and identify how they can be used to:

• Build local community members’ confidence and capacity to organise and become considered a “Key Stakeholder” by local NHS providers and commissioners;
• Help them inform and shape local commissioning decisions in a context where there are difficult decisions to be made;

Provide a sustained national voice on the ‘community value’ of community hospital care provision. 

As with the research study as a whole, the impact activities outlined within this application have been co-designed and will be co-delivered with key stakeholders, particularly through community hospital Leagues of Friends, the CHA and community hospital staff.

“ the NHS also needs a more fundamental shift in how we work alongside patients and individuals to deliver more person-centred care, recognising […] the importance of ‘what matters to someone” (NHS Plan, 2019, p24).

Planned activities

The impact activities are aimed to deliver practical, instrumental and conceptual impact through influencing the development of health and social care policy and practice and contributing to a new understanding of the role and value of community hospitals.

In partnership with key members of the CHA and case study site stakeholders we have identified a range of actions to maximise the impact from of this study:

Local capacity and confidence building to help inform and shape local commissioning decisions and plans 

• A series of local events, will be supported by the University of Birmingham and the CHA, and organised and hosted by case study Leagues of Friends in collaboration with other local stakeholders including people who were members of the Local Reference Group, patients and family carers.
• A series of resources are being developed to enable local groups such as Leagues of Friends and CHA members to use the study findings.

Provide a sustained national voice on the ‘community value’ of community hospital care provision

This will be achieved through:

• A CHA planned national campaign
• University of Birmingham dissemination

Jon Glasby
Deborah Davidson
John Mohan
Iestyn Williams
Angela Ellis-Paine 
Daiga Kamerade
Russell Mannion
Nicholas Le Mesurier
Tessa Crilly (Crystal Blue Consulting)
John Crilly (Crystal Blue Consulting)
Helen Tucker (Community Hospital Association)
David Seamark (Community Hospital GP lead)
Bradford Institute for Health Research (Prof. John Young) 
RAND Europe (Dr Ellen Nolte).

Analysis of the profile, characteristics, patient experience and community value of community hospitals: a multimethod study. Health Serv Deliv Res 2019;7(1) https://doi.org/10.3310/hsdr07010

Seamark D, Davidson D, Tucker H, Ellis Paine A, Glasby J. The changing role of GP clinicians working in community hospitals. Br J Gen Pract 2019. DOI: https://doi.org/10.3399/bjgp19X701345

Analysis of the profile, characteristics, patient experience and community value of community hospitals (Illustrated Scientific Summary) (PDF)

Analysis of the profile, characteristics, patient experience and community value of community hospitals: a multimethod study (Plain English Summary) (PDF)

What can the development of community hospitals in international contexts tell us about their role in healthcare futures?

5 November 2020

The core presentation looked to address three questions:

1. What can the development of community hospitals in international contexts tell us about their role in healthcare futures in England?
2. How has your thinking on this changed during Covid-19?
3. How does recent research evidence – particularly from the RAND study – inform these debates? 

Research Presentations:

• Dr. Emma Pitchforth, Exeter University
• Professor Ellen Nolte, London School of Hygiene & Tropical Medicine
• Professor Edwin Van Teijlingen, Bournemouth University 

Panel:

• Professor Sir Lewis Ritchie, University of Aberdeen
• Associate Professor Verdiana Morando, Gulf Medical University
• Helen Tucker, President, Community Hospitals Association
• Dr Alastair Noble, Chair, Scottish Association of Community Hospitals

Are community hospitals an effective and efficient way to deliver intermediate care and what might this mean for their future role?   

12 November 2020

Presenters were asked to reflect on how the findings from the Leeds/MOCA research study inform the debates on the future of community hospitals, addressing the key seminar question.

Research presentations

• Professor Claire Hulme, Exeter University
• Dr. Helen Tucker, President, Community Hospitals Association 

Panel:

• Chris Humphris, Chair, Community Hospitals Association
• Clare Holditch, Director, NHS Benchmarking Network
• Barry Nealon, Chair, Rye, Winchelsea and District Memorial Hospital

How are community hospitals valued by their communities, and beyond, and what might this mean for their future role?

19 November 2020

Presenters were asked to reflect on how the findings from the Leeds/MOCA research study inform the debates on the future of community hospitals, addressing the key seminar question. 

Research presentations

• Deborah Davidson, University of Birmingham
• Dr Angela Ellis Paine, University of Birmingham 

Panel

• Dr David Seamark, Director, Community Hospitals Association
• Dr. Ellen Stewart, University of Edinburgh
• Heather Penwarden, Chair, Honiton Community Hospital League of Friends

Deborah Davidson and Helen Tucker spoke about the Study of Community Hospitals at Gloucestershire Health and Care NHS Foundation Trust’s Celebrating our Community Assets conference on 27th November 2019.