Community Hospitals

One of the main planks of the BHSP concerns intermediate-care. It is proposed that patients in the recovery phase of their illness no longer stay in acute hospitals unless there is a compelling reason why this should not be the case. Some would go home earlier than would otherwise have been the case with augmented community support. Others will go to a community hospital this would usually be a staging post on the way home. It seems that this is the principal, although not the exclusive, \"driver\" for the proposed increase in the number and scope of community hospitals in Bristol. Other possible funtions suggested includeoutpatient services, some diagnostic services (eg X-Ray), physiotherapy, and minor injuries management.

It seems appropriate at this time to briefly review the present national position regarding community hospitals. This article is not intended to be a comprehensive evidence-based review but rather it represents an attempt to identify some of the key facts and issues particularly as they relate to Bristol. In compiling this article I have been greatly helped by articles written by, and discussions with, David and Clare Seamark both General Practitioners in Honiton and by Vicky Wood who is R and D support manager with Bath and Swindon RDSU.

Community hospitals are local hospitals, units, or centres whose role is to provide accessible health care and associated services to meet the needs of a clinically defined and local population. As an extension of primary care they enable GPs and primary health care teams to support people within their own community. \"Community hospitals play a major role in rehabilitation and also offer palliative care, health promotion, diagnostic, emergency, acute, and therapeutic services\" (Seamark D et al).

Seamark et al undertook a questionnaire study of community hospitals in the United Kingdom (Seamark D et al). A total of 471 community hospitals were identified. The total number of beds was 18,579. The median number of beds per hospital was 33 (range 20-50). The mean distance from the district general hospital in miles was 14.

8,457 beds were GP-led. 10,122 beds were consultant-led. Over three-quarters were described as medical and elderly care beds with 4% being surgical and the remainder consisting of maternity, assessment, palliative/terminal care, rehabilitation, stroke care, post-operative and a few nurse-led beds.

There were 7,424 general practitioners with admitting rights representing 2,191 practices. This was 20% of the current GP workforce. GP practitioners worked as GP clinicians, clinical assistants, or hospital practitioners in 87% of UK community hospitals. Consultant out-patients clinics were held in 66% of the hospitals covering most medical and surgical specialities.

Most of the hospitals had access to physiotherapy and occupational therapy. Plain x-rays were available in 63%. Contrast x-rays were available in 15. Ultrasound was available in 32%.

Comparisons were made with a previous study that had been undertaken in 1983. This identified 425 such hospitals. In 1990, 415 hospitals were identified. Between 16,000 and 17,000 community hospital beds were identified in the 1980s compared with around 18,500 at the beginning of 2000. Around one in 5 GPs were involved in community hospital work. Intrapartum obstetric services were identified in 16% of UK community hospitals in previous studies. However subsequent data has shown many of the hospitals have stopped undertaking obstetric work. Some solely midwife-led units were identified.

It was concluded that there had not been any substantial reduction in the number of community hospitals in recent years.

As we point out above more than half of community hospital beds were \"consultant-led\". It does, therefore, seem that consultants are closely involved in the running of at least some of these hospitals.

A paper published by Hull and Jones in 1995 addressed the issue of whether or not there was a demand for inner city community hospitals. They concluded that about two-thirds of general practitioners supported the idea. Patients satisfaction with such units was said to be high.

I am not aware of any published studies dealing with city-based community hospitals. It is understood that Exeter has a consultant-led community hospital. Junior hospital doctors provide cover during the day and general practitioners provide night-time cover. Dr Alison Round is undertaking a case-matched study of patients who go to community hospitals or to acute hospitals. The results have been accepted for publication but the paper has not yet been published. There is a multi-centre study being undertaken at Bradford supervised by Dr John Young. This is another \"ongoing\" study and I have spoken to the Project Manager. This is a multi-centre, randomised, study between community hospitals and \"normal care\". They are also undertaking a single centre study but this is not yet published.

1. Bed blocking. David Seamark expressed the opinion that bed-blocking is not a worse problem in community hospitals than it is in acute hospitals. However no definite information on this point is available.
2. Pay. David Seamark pointed out that if General Practitioners are to be closely involved in the running of community hospitals it would be essential to get the pay structure for them right. At one time general practitioners were paid virtually nothing for looking after people in such hospitals. However this has now changed since the introduction of the new work contract.

This issue was addressed by Hine, Wood and others in a paper published in 1996. Examination of routinely gathered activity data in the Bath Health District revealed that availability of community hospital beds was associated with reduced use of central in-patient services in the City of Bath. This reduction was most apparent for medical and geriatric beds. Decrease in the use of surgical beds was small. However, total in-patient bed use (including central and community hospital beds) was higher in the population with access to community hospital beds.

I undertook a Medline search covering the years 1995 to 2004. There are few high-quality papers. In particular there appeared to be a lack of information regarding inner city community hospitals. This problem is clearly being recognised and there are a number of ongoing studies including one in Exeter. I was surprised to find that consultants, presumably many geriatricians, do have clinical responsibilities in community hospitals. On the face of it this seems to be a desirable situation but little is known about the experiences of consultant staff and their juniors. This matter is clearly of much relevance to Bristol where a number of urban community hospitals are planned.

Little seems to be known about the precise clinical needs of patients being looked after in community hospitals. This seems to be a matter that requires further investigation.

It seems that many community hospitals are used as an out-patient base for specialist clinics.

There is a need to better define the contribution of community hospitals in health care particularly of older people in urban areas. The arguments for expansion appear to be based to some extent upon expediency. There is no clear-cut clinical outcome or economic evaluation. There are a number of published papers that discuss the situation in further details see below.

Brooks,N. 2001. Length of stay in community hospitals. Nursing Standard.15(27) 33-8.

Young J and Donaldson K.2001. Community Hospitals and older people. Age and Ageing.30/53; 7-10.

Church.J. Seamark D. 2002. A survey of surgical activity in UK community hospitals. Annals of the RCS 84(2):111-112.

Donald IP, Linsell J and Foy C. 2001. Defining the use of community hospital beds. British Journal of General Practice. 51:95-100. (This study was undertaken in the elderly care unit at the Gloucestershire Royal Hospital

Hine C, Wood V A et al 1996. Do community hospitals reduce the use of district hospital in-patient beds? Journal of the Royal Society of Medicine 89; Pgs 681-687

Hull SA and Jones I. 1995. Is there a demand among general practitioners for inner city community hospitals? Quality in Health Care. 4. 214-217.

Seamark D, Moore B et al. 2001. Community hospitals for the New Millenium. British Journal of General Practice. 51. 125-127

Tomlinson J, Raymond N T et al 1995. Use of general practitioner beds in Leicestershire community hospitals. British Journal of General Practice 45; Pgs 399-403

RLH March. 2004.