SHIFTING THE BALANCE OF CARE - NEW COMMUNITY HOSPITALS
Expanding the vision of community hospitals
The current distribution of community hospitals reflects history, rather than any single overall plan. Most community hospitals pre-date the NHS and many were established in small towns by local benefactors. Others were built with local donations as war memorials or as fever hospitals. Many community hospitals have a strong symbolic importance for communities, providing a breadth of locally available services which benefit from a sense of local ownership.
Services currently provided in community hospitals also reflect history. The time has come to embrace an expanded vision of the new community hospital with or without beds, that is fit for purpose and part of a rethink of related health and social care.
Two key strengths of community hospitals are that:
- they can provide local access to a wide range of services, potentially on a 24-hour, seven-days-a-week basis
- they can promote a multi-disciplinary, multi-sectoral approach to healthcare.
The foundation provided by community hospitals gives an excellent platform on which to develop community health resources to meet current and future needs.
The new community hospital will act as a local community resource centre and provide a bridge between home and specialist hospital care, through the delivery of both ambulatory and/or inpatient services closer to communities.
The new community hospital as a local community resource centre
Delivering for Health emphasises the need for locally accessible resource centres to enable the co-location of 'traditional' community and primary care, nursing, social work and voluntary sector personnel, working with visiting consultants and outreach service providers. This co-location of skills and expertise will foster a culture of collective understanding, shared information and flexible skills development, helping to ensure that there is a breadth of skills across the team and long-term sustainability of services.
The new community hospital will be ideally placed to fulfil this role. The aim should be to enable local primary care resource centres and local community nursing services to provide the bulk of care for the local community alongside local general practices.
Staff operating from community hospitals functioning as a community resource centre will co-ordinate complex packages of care involving multiple agencies and addressing both health and social care needs. Research studies have shown that community hospitals are particularly good at taking a patient-centred approach to identifying care needs and delivering the necessary care packages.
Community nursing teams, working from a new community hospital, will be well placed to contribute to ongoing care and other service developments such as unscheduled care/out-of-hours ( OOHs) services.
Developing community hospitals as primary care resource centres will open the door to partnerships being formed with the local community in providing a range of health-related community activities in the daytime and at evenings and weekends. Physical activity classes, complementary therapy sessions and supportive activities for mental health service users are possible examples. Clinical pharmacy and other specialist and supportive services also have an important role in the provision of local services.
New community hospitals should be local community resource centres in which to provide people with more holistic and integrated services quicker and closer to home.
NHS Boards are encouraged to develop this agenda in partnership with and with the support of others in the NHS, such as the Scottish Ambulance Service and NHS 24.
Urban community hospitals
People tend to associate community hospitals with remote and rural settings, where larger hospitals may be many miles away. However, in urban settings there is still a need for local provision of services away from large acute and specialist hospitals. This may not include a need for inpatient beds depending on the identified needs of each area. Urban community hospitals have the potential to make a real difference to local areas with significant health needs.
There is a growing number of such community-based centres in urban settings, for example:
- The Links Unit in Aberdeen City: a 24-bed urban community-based facility offering GPs an alternative to admission to the acute sector for medically stable older people. It provides nurse-led, GP-supported care with a focus on the promotion of independence through rehabilitation and co-ordinated health and social care.
- The Leith Community Treatment Centre in Edinburgh provides healthcare for local people in the centre of their community. As well as providing a range of diagnostic services and outpatient clinics, including paediatrics, it also offers rehabilitation assessment for older people and services such as dietetics, physiotherapy, midwifery and community dentistry. Co-located services include social work, psychiatric nursing, voluntary services and school nursing. There are no inpatient beds.
NHS Boards should adopt the new community hospital model for urban use, providing services more locally.
Service provision at community hospitals
As these examples show, the range of services delivered in community hospitals should be based on an analysis of local needs and existing services. The following sections describe some of the services that might be delivered from the new community hospitals we envisage.
Planned care
Community hospitals will strengthen the primary-secondary care interface by providing intermediate care. They are well positioned to facilitate timely discharge of people from larger hospitals and to provide pre-admission and post-discharge care from these hospitals. Community hospital staff have an important role in supporting the proactive management of long-term conditions and the prevention of crisis episodes.
Admission to a large acute hospital can have adverse effects on individuals, especially older people, such as undermining personal confidence, and the dislocation of local support structures and family networks. Community hospitals offer the ideal environment in which to provide care and treatment for patients with health needs who cannot be cared for at home, but who do not require the level of specialist care provided in an acute hospital. By providing services more locally, it is anticipated that the length of admission might be shortened by the improved co-ordination of discharge planning and the positive effects of maintaining community links for the patient.
In addition, community hospitals could provide more ambulatory services locally avoiding lengthy journeys for individuals and potentially preventing admissions to acute hospitals for diagnosis and treatment merely because of the logistics of travel.
NHS Boards should look at the role of community hospitals in providing a range of planned care services.
NHS Boards should design services using a whole systems approach which understands and responds to the needs of the local population. In so doing, they should consider which of these needs can be met by new community hospitals and whether there is a need to move particular services either into or out of the new community hospital environment.
More specifically planned care services could include:
(a) Day case surgery
The vision of community-based services set out in Delivering for Health and the expansion of day case surgery now offer opportunities for a greater number of planned surgical procedures to be carried out locally in a community hospital.
Examples of day case surgery already being delivered are:
- a day case vasectomy service at Kincardine Community Hospital in Stonehaven through a locally based accredited GP
- plastic surgery day case services such as melanoma removal at Brechin Community Hospital, provided by a visiting specialist plastic surgeon
- minor surgery services at many community hospitals provided by local GPs.
(b) Pre-admission assessment and post-operative aftercare
The individual's journey for elective surgery in larger hospitals would be improved through the provision of pre-admission assessment and post-operative aftercare in community hospitals. Investigative procedures such as x-rays and blood tests could be performed before admission to larger hospitals and patients could be discharged to the local community hospital for inpatient post-operative care and rehabilitation or outpatient follow up. Many community hospitals already admit orthopaedic and other post-operative surgical patients.
(c) Planned day care and rehabilitation
This could include people requiring palliative and terminal care, ante-natal and post-natal care and patients requiring rehabilitation for conditions such as stroke. Community hospitals could provide and develop rehabilitation services, supporting people at home or providing a homelike environment for patients within their own locality.
(d) Diagnostics and treatment
The list of possible diagnostic and treatment services which could be delivered by community hospitals ranges from complex high technology services, through endoscopy and diagnostic ultrasound/x-ray, to simple near-patient testing and anticoagulant monitoring.
(e) Outreach clinics and GPs/health professionals with special interest
Many community hospitals in Scotland already have outpatient clinics so that patients do not have to travel far for appointments. These clinics can be run by visiting consultants, but consideration should be given by NHS Boards to provision of services by GPs, nurses and other health professionals with special interests, for example mental health and speech and language therapists.
In summary, the new style community hospitals could provide:
- day case surgery
- pre-admission and post-discharge care (intermediate care)
- planned admissions where specialist care is not required or could be accessed remotely
- a wide range of diagnostic and treatment interventions
- outreach outpatient services run by consultants and/or health professionals with special interests.
Unplanned care
Many people are admitted as emergencies to hospital to receive diagnostic services or to treat an exacerbation of a long-term condition. The nature of someone's problem should always dictate where he or she is treated, and some people will always require the expertise and resources of a specialist acute centre. Others, however, could safely and effectively be cared for locally at community hospitals with appropriate resources of personnel, equipment and telecommunications capability. Nurses and allied health professionals have opportunities to develop their role further to meet people's needs in these areas. More specifically, new community hospitals might provide the following type of unscheduled care services:
(a) Community casualty units
Delivering for Health made a commitment that NHS Boards would develop practitioner-led community casualty units. The vision is that hospital-based specialist emergency centres will deal with serious and life-threatening emergencies, while community casualty units, led by a range of practitioners such as GPs, nurses and paramedics, could provide for the approximately 70% of current attendances at accident and emergency departments that do not require hospital attendance.
Some community hospitals already have practitioner-led minor injury units, so adopting community casualty unit status could be a logical next step. The
co-location and integration of a community casualty unit with a local OOHs service in a community hospital would make sense in a number of areas.
NHS Boards should look at community hospitals as potential sites in which to base community casualty units, with possible co-location of OOHs centres.
(b) Investigations before, or instead of transfer
Extending primary care professionals' access to community hospital investigative and diagnostic facilities would enable patients presenting as emergencies to be diagnosed and possibly treated locally, with links and referral to specialist centres as appropriate. This service development would be enhanced by the possibilities of telehealth with the capacity for remote consultation and results reporting as described later. Those patients requiring transfer to the specialist centre may be considered for post-discharge treatment and/or rehabilitation at the community hospital.
(c) Stabilisation prior to transfer
Community hospitals in many remote and rural areas of Scotland already provide essential treatment to people, stabilising their condition prior to transfer to a specialist centre. Local GPs and teams at community hospitals offer, for example, thrombolytic therapy to patients who have suffered a heart attack. This function could be considered in other community hospitals as part of the overall planning of unscheduled care.
(d) Local special skills development
It may be possible to develop this model further, for instance the local extended primary care team at the Mid Argyll Hospital in Lochgilphead, provides treatment to seriously ill emergency patients, including airway management and assessment and management of head injuries, prior to transfer via the Rapid Retrieval Team to the acute unit at the Southern General Hospital in Glasgow.
In summary, some community hospitals could provide:
- community casualty units
- pre-transfer investigation of an acutely ill patient prior to transfer to an acute hospital
- pre-transfer stabilisation of those who need to be admitted
- local special skills development which will support this process and co-located OOHs centres.
Sustaining and developing communities
Communities and stakeholders have been clear about the wider role community hospitals play in their local context. They not only fulfil a key health care function, but also provide employment and are a source of community pride and identity, consequently contributing to what has come to be described as 'social capital' - the idea that communities working together create benefits for the whole community and for the individuals within it.
Many people in communities feel ownership of community hospitals and are positively supporting them and undertaking voluntary work. NHS Boards can utilise the energy of local communities in developing the role of community hospitals by:
- setting up links with voluntary and volunteering organisations, carers and carer organisations, care providers (including those in the social, private and care home sectors) and local businesses
- being responsive to new opportunities to work with and for the community.
Community Health Partnerships and local management recognise the investment local people and stakeholders have in the service. These groups must be involved at the earliest possible stage in thinking about new developments, identifying innovative, locally orientated models, planning their implementation and evaluating their effectiveness.
This strategy presents an important opportunity for modern community hospitals to develop and grow and for local communities and other stakeholders to be involved and to reap the benefits.
NHS Boards must recognise and harness the investment local communities have in community hospitals and involve them at all stages of development and delivery of services.
Examples of ongoing practice can be found at www.scotland.gov.uk/Topics/Health/NHS-Scotland
The new community hospital will act as a local community resource centre and provide a bridge between home and specialist hospital care, through the delivery of both ambulatory and/or inpatient services closer to communities.
New community hospitals should be local community resource centres in which to provide people with more holistic and integrated services quicker and closer to home.
NHS Boards are encouraged to develop this agenda in partnership with and with the support of others in the NHS, such as the Scottish Ambulance Service and NHS 24.
NHS Boards should adopt the new community hospital model for urban use, providing services more locally.
NHS Boards should look at the role of community hospitals in providing a range of planned care services.
NHS Boards should design services using a whole systems approach which understands and responds to the needs of the local population. In so doing, they should consider which of these needs can be met by new community hospitals and whether there is a need to move particular services either into or out of the new community hospital environment.
NHS Boards should look at community hospitals as potential sites in which to base community casualty units, with possible co-location of OOHs centres.
NHS Boards must recognise and harness the investment local communities have in community hospitals and involve them at all stages of development and delivery of services.