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Collaborative working among staff is likely to be the best way to improve performance in smaller hospitals, a new study concluded. It explored the approaches smaller hospitals take to organising emergency care for people admitted to hospital. There were huge variations, but no single way of working (‘model of care’) was more effective than others.

The study included 50 hospitals and compared their numbers of specialists (who focus on a single organ) with medical generalists (doctors with a broader range of skills). No two hospitals arranged care in an identical way. However, in general, hospitals did not match the skills of their medical staff to the needs of their patients.

Growing numbers of people needing emergency inpatient care are over 60 and have multiple conditions. They may be admitted for one condition while having other conditions that need consideration. Despite these changing needs, there has been little research to explore how care for these patients should be organised and staffed. This study set out to address this research gap.

The new research highlights the need for smaller hospitals to carefully plan recruitment to reflect the mix of patients they treat, and to encourage more collaborative working.

What’s the issue?

For the last 20 years, care within hospitals has come to be organised around different medical specialties. Doctors who are specialists in diseases of a single organ, for example a cardiologist (heart) or respiratory physician (lung), oversee an individual’s care. This is a specialist-led model of care.

The specialist-led approach is being called into question because of rising numbers of older people with multiple long-term conditions. This model of care may be effective in large hospitals, but it could be less appropriate in smaller hospitals, with fewer staff.

Historically, care was delivered by doctors with general skills, such as geriatricians or general physicians.  A return to this generalist model of care is being called for. As the population ages, more people have complex and multiple needs. Doctors with generalist skills could be well-equipped to manage their conditions.

However, there has been little research into the different models of care within hospitals, and how the models impact on the quality and cost of care.

This study explored different models of care in smaller hospitals. It assessed the strengths and weaknesses of the various models from patient, service and professional perspectives.

What’s new?

This was the first attempt to systematically map and compare people’s journeys through hospitals from admission to discharge (patient pathways). The study included all 69 smaller hospitals in England and focused on emergency and acute services (which provide urgent short-term treatment for illness or injury).

For 50 of the hospitals, the team gathered data on the conditions people had, and looked at the model of care in use. Researchers carried out 11 case studies to explore how well different models of care were matched to the needs of the local population. Then, through questionnaires and interviews, they explored the preferences of 173 doctors, 9 hospital managers and 20 patients for generalist versus specialist care.

Models of care

Smaller hospitals offered a mix of specialist- and generalist-led care, the study found; their models contained elements of both. There was a spectrum of models from more generalist- to more specialist-led care.

Hospitals varied in how they staffed and organised patients’ assessment in the acute medical unit (for the first 24-72 hours of care) and the wards patients were admitted to afterwards. No two hospitals had identical systems of care. Furthermore, models of care frequently changed when hospitals were under pressure.

While the models of care were highly varied, the needs of the people they admitted were broadly similar. Most patients were suitable for care by medical generalists.

The economic analysis found that costs did not differ according to the model of care or the proportion of medical staff in the hospital who were generalists.

The model of care in place was not responsible for outcomes. The interviews suggested that differences between hospitals in outcomes and costs were due to hospital-level factors (such as leadership, financial resources, and local context).

Doctors’ preferences and ways of working

Doctors were more willing to work as generalists if this approach was supported by their training and previous experience. The study concluded that creating more collaborative working environments was more likely to improve care than changing the model of care.

Patients’ preferences

Given a hypothetical choice in a survey, people tended to say they would prefer care given by specialists over that given by generalists. However, in an online survey, they also said that overall hospital quality was more important to them than whether the care was given by a generalist or a specialist.

The researchers concluded that, in areas where many people have multiple and complex needs, a generalist approach may be better suited to caring for an ageing population than a specialist approach. Environments that actively support generalist working will be more able to deliver high-quality care, they said. Good collaboration between teams made more difference than the model of care in use.

Why is this important?

The rising number of older people with complex needs is a major healthcare challenge. These people are the most intensive users of hospital inpatient care, and the care they receive is often poorly coordinated.

National strategies, such as Getting It Right First Time, aim to reduce variation in surgical practice. They have successfully reduced costs and improved efficiency. Strategies for surgery are based on sound evidence and shared understanding of best practices. By contrast, this study found that models of medical care are not driven by solid evidence or an agreed theoretical framework. Instead, they develop in response to a range of local factors.

No model of care emerged as being better than any other. Outcomes depended on hospital-level factors such as their overall management. The variation in the size and staffing of hospitals would make it difficult to have a standardised model. A ‘one size fits all’ approach may not be appropriate to guide best practice in emergency and acute medicine in smaller hospitals.

Empowering organisations to adapt their staff model to meet local requirements may be a more productive approach. For example, encouraging staff with different skills to work collaboratively together could help meet local patient needs.

What’s next?

The researchers hope that as a result of this work, hospitals will look more carefully at the needs of their population. They suggest that care should be organised, and staff recruited to better meet those needs. In particular, they hope that hospitals will recruit more doctors with generalist skills, and encourage greater collaboration between medical specialists and generalists.

Some of the hospitals that took part in this study have already analysed their medical admissions, using methods developed for the study. They have adjusted the size of their medical wards to meet the likely needs of patients, ensuring that they can be cared for by the most appropriate team. Other hospitals have looked at their pathways of care and have reduced complexity, thereby improving flow through the hospital. The study contains other practical suggestions on how systems and pathways of care can be improved.

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This NIHR Alert is based on: Vaughan L, and others. Models of generalist and specialist care in smaller hospitals in England: a mixed-methods study. Health Services and Delivery Research 2021;9:4

It’s not just about the front door of the hospital: lessons from the medical generalism in smaller hospitals study - a blog post from the Nuffield Trust about this article.

Multimorbidity – the biggest clinical challenge facing the NHS?: a blog on the NHS website about multiple morbidities.

‘Smaller hospitals: deserving of support at every level’ - a blog post about the challenges faced by smaller hospitals.

Funding: This study was funded by the NIHR Health Services and Delivery Research programme.

Conflicts of Interest: Several of the authors report a conflict of interest. One of the authors works for the NIHR but was not involved in the selection of this paper.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


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