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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.

You may be interested to read

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 Centre for Engagement and Dissemination 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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Study author

Smaller hospitals can’t support the specialist models of care that work in larger hospitals. We found that it was appropriate for them to use different models. In general, there is far too much emphasis on changing models of care. Our work suggested that focusing on aspects of patients’ pathways would be more productive than wholesale reform.

We want to see better patient outcomes and a faster flow of patients through the system. Our study identified major issues with continuity of care – regardless of the model used. Each time a patient changed consultant or team, their hospital stay increased by 2 days. More collaborative working would increase continuity of care and smooth patient pathways. This could mean they are discharged earlier.

Staff attitudes are key to patient care. In hospitals where collaboration is prioritised, patients are everybody’s responsibility, regardless of whether staff are specialists or generalists. Collaborative environments are not built overnight. They depend on strong leadership and staff willingness to adopt the ethos.

Louella Vaughan, Senior Clinical Fellow, The Nuffield Trust, London 

Royal College of Physicians 

For at least a decade the medical workforce has not been able to meet demand. There is on average a 43% underfill of consultant physician posts in the UK with geographic variation pushing this figure up to 75% in some areas. Smaller hospitals are more affected by under-resourcing.

This innovative piece of research establishes for the first time that the model of care in smaller hospitals (specialist or generalist -led) does not determine care outcomes. This undermines the theory that a single model of care across the NHS is the correct policy approach.

What is predictable however, is the emergency medical care case mix of patients across a spectrum of small hospitals. When workforce planning therefore, patient need is a ‘predictable factor’ and needs to guide local adaptability in the model of care provided and the type of workforce recruited. Not surprisingly the quality of leadership and organisational culture (collaborative) impact strongly on the willingness of doctors to perform generalist duties. Doctors were also more willing to work as generalists if this approach was supported by their training and previous experience.

As the population demographic of the UK changes further towards the elderly, multi-morbid patient, workforce expansion and training of doctors need to address the findings of this research by equipping new consultants with confidence and experience to manage complex care needs and by prioritising the subspecialty skills demanded by the case mix.

There is a workable balance to be had between the well trained holistic general physician, whose professional status needs to be resurrected as equal to that of the sub-specialist and the ability to develop consultants as to high levels of expertise in their own areas of practice. The implications for Shape of Training may be that we need to acknowledge that the confidence for such combined practice will require a longer training period than currently is allowed.

What is clear is that case mix and local variation needs to define the model of care locally as Integrated Care Boards become established.

Cathryn Edwards OBE, Registrar, Royal College of Physicians 

Member of the Public 

It never crosses many people’s minds that there are differences in standards of care in UK hospitals. The general perception is that, with a few exceptions, the care and treatment they get in one district hospital is the same as in another. Finding out that most models of care are in a constant state of flux and frequently break down is worrying.

The care patients receive at hands-on level depends on far more than policies, protocols and procedures issued by management. The report indicates the need for better collaborative working. But unless there is effective collaboration at every stage, fixing one part of it doesn’t really solve the problem for the patient. The whole working environment needs to be collaborative.

At the moment, care is based on where people are rather than what they need. I’ve seen patients with multiple conditions struggle under a specialist model. They are seen by a specialist renal (kidney) consultant, for example, then a day or so later, by an endocrinologist (who treats hormone-related diseases). The only coordination of care is at a multi-disciplinary team meeting once a month. All this delays their recovery and discharge.

A large part of the problem lies in the culture of tribalism within medical (and surgical) teams. This research emphasises the need for better collaboration.

Jeremy Dearling, Public Contributor, Norfolk 

Researcher 

The substantial variability both between and within the models of care was perhaps unsurprising. However, high-level planning and strategic aims at hospital level were associated with more stable and mature models of care. Furthermore, staff viewed hospitals with skilled and stable leadership teams promoting cultural change, as more desirable places to work. Strong leadership could reduce staff turnover and further stabilise the systems of care.

This influence of organisational culture is not a new concept. As healthcare systems struggle to meet demand in the wake of 18 months of pandemic, reorganisation of NHS workforce and processes is being considered as a potential solution.

This research could have an impact at a strategic and commissioning level. The differences in acute emergency medical case mix between hospitals was found to be small. The findings therefore suggest that smaller hospitals could be encouraged to develop models to meet local needs and circumstances. They do not need to base their service delivery on approaches used by larger hospitals. This could improve patient care and benefit the wider NHS.

The demarcation between generalist and specialist was unclear for most models. This means that confidence in any comparison between models is low and the authors rightly conclude that the reliability and reproducibility of the results are limited. Further challenges were related to issues with data reporting at a Trust/hospital level and uncertainty about economic costs.

Sarah Voss, Professor of Emergency Care, University of the West of England 

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