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The Future of Community Hospitals

15th April 2007

The Department of Health hailed community hospitals as a key part of the health reform agenda last year, at the same time as several community hospitals across the country were under threat of closure. What is being proposed for community hospitals, and how does the policy reconcile with the reality of local service pressures?

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The new policy context

Following a high profile consultation and listening exercise, the government published the white paper Our Health, Our Care, Our Say in January last year. Coming at the half way point in the delivery of the ten year NHS Plan, the White Paper marked a shift in policy focus from access and capacity concerns to a more patient focused agenda. Its major themes were:

• More investment in preventative and primary healthcare.

• New care pathways to keep patients out of acute hospitals.

• Better joint working between health and social care to provide joined up care plans.

• Care personalised to individual patients.

• Greater patient choice of services and providers.

A key part of this was the announcement of a ‘new generation’ of community hospitals which, it is proposed, would deliver 5% of NHS care in the future. These are intended to help shift care from acute settings closer to patients’ homes by providing a variety of services such as:

• Diagnostics eg x-ray, ultrasound, mobile MRI, haematology and biochemistry testing, and some cardiac tests.

• Day case procedures and minor surgery eg endoscopy and biopsies.

• Outpatients.

• Step up/step down intermediate care.

• Cardiac and stroke rehabilitation services.

• Local cancer care eg administration of chemotherapy.

• Palliative care.

• Urgent/unscheduled care in facilities such as Walk In Centres and Minor Injuries Units.

• Multi-disciplinary team assessment of older people.

• Base for community mental health teams.

• Base for social services, including access to benefits and employment advice.

• Self-help/expert patient groups.

They would not provide A&E services or surgery requiring general anaesthetic.

Making use of new technologies such Picture Archiving and Communications Systems (PACS) will help new community hospitals to do more for patients away from acute hospitals. The Department proposed to work with the Royal Colleges over the course of last year to develop new pathways of care that avoided acute hospitals and defined a clear role for a new breed of community hospitals.

Further guidance from the Department of Health last summer suggested that new community hospitals would be based around populations of approximately 100,000. It put forward four broad types of new community hospitals, indicating that inpatient beds do not have to be part of the service complement in these new facilities. Some would essentially be pared down old District General Hospitals (the new Edgware Community Hospital is a current example), and some would be similar to the outpatient based polyclinics established in Germany in recent health reforms there.

Who would build, own and run the new community hospitals?

The Department announced a capital fund of £750m (£150m a year for 5 years) to support the development of new community hospital facilities. What was clear, though, is that this is not about renovating the old Victorian cottage hospital, but about developing new state of the art community facilities. As of April 2007 nearly £100m of the capital fund had been allocated to scheme to build new or refurbish existing commuinty hospitals, and to build new health centres.

Community hospitals in the future do not have to be built, owned and run by the NHS. The Department of Health is keen to experiment with alternative models, including using the LIFT financing scheme, and other kinds of private public partnership. There are already examples where ‘third sector’ organisations such as charitable trusts have taken over ownership of a community hospital asset from the local PCT and taken on responsibility for the running of its services. Acute trusts and Foundation Trusts could also look to take them on and manage a larger portion of the overall patient care pathway.

How will community hospitals be funded?

The government is clear that revenue needs to be diverted from the acute sector to support a shift of services to the community. It is looking at how elements of the Payment by Results tariff can be ‘unbundled’ to allow parts of tariffs to be invested in community care rather than the whole tariff value going to the acute provider. Rental income could also be generated by new community hospital facilities being used by a wider range of patient service organisations.

What is yet to be definitively established, however, is whether caring for patients in community settings is actually cheaper than treating them in the acute sector. Unless this can be proved, no one really understands the true financial impact of the policy change set out in Our Health, Our Care, Our Say.

Why are community hospitals under threat of closure then?

The Conservative Party welcomed what it called a u-turn in government policy from closing to saving community hospitals. The Community Hospital Association said that at the end of September 2006, of the 320 community hospitals in the country:

• 11% were under threat of closure or service downgrade.

• 11% were under review as to their future.

• 1% were temporarily closed.

• 3% had been closed in recent years.

In Wiltshire, for example, a number of small community hospitals have been or are about to be closed whilst services, such as midwife-led birthing units, are being centralised to the few remaining community hospitals in the county. The changes have taken place along side an investment in neighbourhood teams caring for patients in their own homes, and upgrades in services in the remaining community hospitals. But the county’s PCT is carrying a significant deficit, and there are concerns that the service reconfiguration has been driven primarily by the need to make savings rather than a desire to move to a new model of care. The picture of financial deficit and community hospital closures is being replicated in many health communities round the country.

In light of this and the new policy context, the Department of health has made it clear that no community hospital should close because of short term financial difficulties. Proposals for closure will only be supported if PCTs can demonstrate that they have looked into and consulted widely on new care pathways which would make more use of a threatened facility, and found that they are not viable. Whether this would ever be possible to do, and whether the NHS can attain the government’s policy aspiration whilst trying to hit break even is yet to be seen.

For more information on the development of community hospitals go to:

http://www.dh.gov.uk/assetRoot/04/13/69/32/04136932.pdf

http://www.changeagentteam.org.uk/index.cfm?pid=53

http://www.institute.nhs.uk/ServiceTransformation/the_productive_community_hospital.htm

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