What is a community hospital?

Community hospitals have evolved over time to become a diverse set of institutions that present a challenge to any attempt to define, categorise or map them. Our initial attempts to develop a definition based on a comparison of inpatient metrics, population characteristics and service provision found that community hospitals were distinct from other types of hospitals through the contribution of GPs and rurality and were typically smaller than acute and DGHs. Beyond these aspects, however, we were not able to identify a definitive set of metrics to determine what should and should not be considered a community hospital. Instead, it was necessary to combine these top-down data with experiential, ‘bottom up’, evidence gathered from community hospital leaders and websites. Bringing these sources together enabled the development of a more comprehensive and inclusive set of defining characteristics, retaining and revising some features identified within earlier definitions^{12,20–22,103,104} (e.g. size, rurality, length of stay, GP leadership), removing others (e.g. population size, localness) and adding new ones (e.g. lack of 24/7 onsite medical cover).

Based on this definition, we identified 296 community hospitals in England in 2015. These hospitals were within a database containing details of each hospital against multiple criteria and were placed on the Community Hospital Association’s website [URL: www.communityhospitals.org.uk/birmingham-university.html (accessed 22 July 2015)]. The overall number of community hospitals remained constant since they were last mapped in 2008,⁷² suggesting resilience within this sector; however, closures and new entrants mean that the make-up of the list shows some differences.

The majority of the community hospitals that we identified were concentrated within rural areas, located in relatively privileged communities, with a bias towards the south of England. This uneven distribution reflects, in part at least, the voluntary nature of their origins and their largely organic evolution.

This definition was taken a step further through the development of a typology, developed through our reading of the literature, analysis of data and conversations with key stakeholders, that recognised community hospitals as operating on a spectrum of intermediate care provision. Core community hospital services were identified as inpatient beds, outpatient clinics and (in half of all community hospitals) MIUs. Alongside these core services, some community hospitals were more orientated towards primary care provision, with others orientated more towards acute care provision.

Implicit within the methodological challenges associated with defining and mapping community hospitals (discussed in Chapter 2), yet somewhat obscured within the results, is the more dynamic reality of community hospitals at the local level. The apparent stability in the total number of community hospitals (until 2015 at least), for example, tells us something about their apparent resilience, but little about the changes that have taken place within them. The mapping alone could not track the declining number of inpatient and maternity beds nor the shifting relationship between community hospitals and other parts of the health-care system, as demonstrated through a reduction in GP involvement, an increase in step-down care and the growing acuity and geographical spread of inpatients. Adding findings from our qualitative case studies to those from our quantitative definitional and mapping work provided a fuller answer to the question ‘what is a community hospital?’. Table 21 summarises what we have come to understand, through the integration of our quantitative and qualitative research findings, as the common characteristics of community hospitals.

TABLE 21

Common characteristics of community hospitals with beds

Community hospitals are diverse and dynamic, but they are united by these common characteristics. Although previous studies have offered various definitions, they were rarely rigorously tested against an analysis of their characteristics; this study has provided a robust list of defining characteristics along with a typology to differentiate among community hospitals and a definitive database on how many community hospitals with beds there are, where they are and what they do.

What are patients’ and carers’ experiences of community hospitals?

Patients and family carers were overwhelmingly positive in ratings of their experiences of community hospital care, support and treatment, thus echoing findings of earlier studies (e.g. Small et al.²⁴). Although we did not set out to make comparisons, many respondents contrasted their experience of community hospitals with that of acute hospitals. Comparisons were favourable (see Green et al.,³² Small et al.²⁴ and Lappegard and Hjortdahl¹⁰⁵ for similar findings), although both were recognised as fulfilling valued, but distinct, functions. Respondents frequently told us that acute hospitals were where you would want to go to treat a specific medical condition, and community hospitals were where you would want to go to get (physically, emotionally and socially) better.

We identified three sets of factors highlighted as being key to patient and carer experiences of community hospitals, as distinct from other types of hospitals:

1. Closeness to home – this encompassed many different functional, interpersonal, social and psychological dimensions, including patients and carers experiencing their locations as more convenient and accessible; their environment and atmosphere as more familiar, homely and relaxed, less stressful and daunting, and more reassuring; and the relationships that they fostered between patients and staff, and between patients, their families and communities, as transformational.
2. Personalised and holistic – closely associated with the elements described above, community hospitals were recognised as providing personalised care. Moreover, a key element of the patient experience was their provision of holistic care. Both were facilitated through community hospitals’ valuable range of co-located, integrated, intermediate services; their fostering of MDT working and, more specifically, of a work ethic that encouraged staff (from different disciplines) to look beyond their professional boundaries to go the extra mile and take care of all the diverse needs any individual patient may present with, while also involving and informing carers.
3. Supporting difficult psychological transitions – for many older people, the accident or illness leading to their admission to a community hospital often triggered a major life event, which was emotionally traumatic and a major psychological undertaking, requiring time to come to terms with such life changes. Trappes-Lomaz and Hawton³¹ suggest that ‘failure to understand patients motivations or their social and psychological realities will risk undermining the rehabilitation process’. Community hospitals were responding in different ways to the demands placed on them through supporting patients through these transitions.

Although this study did not look at outcomes, together these different dimensions of patient experience appeared to help reduce stress among patients and carers and were perceived to aid recovery or, where relevant, to facilitate a ‘better death’. Although there were many examples of staff supporting patients to build their confidence, and a few examples of staff recognising patients’ general anxieties and concerns, we observed little formal assessment and work with anxiety and depression. When caring for older people who, as a result of an accident or illness, were facing a major life change, we would argue that there is a need for a greater focus on people’s psychological, emotional and mental health, alongside their physical health.

Cutting across these different accounts of patient and carer experience are four key dimensions to patient and carer experiences of community hospitals (functional, interpersonal, social and psychological) that we detail below. Previous studies have tended to focus on just two dimensions, the functional and relational (e.g. Glenn and Cornwell¹⁰⁶ and Doyle et al.¹⁰⁷), conflating relational and psychological aspects of care and missing the social. Our study suggests that these should be separately analysed as part of the unique patient experience of community hospitals.

1. Functional, particularly environmental, features of community hospitals were fundamental to patient and family carer experiences, resonating with the findings of earlier studies (e.g. Small et al.,²⁴ Payne et al.²⁵ and Lappegard and Hjortdahl²⁶). These included their accessible locations, small size, often pleasant surroundings, interiors designed to look more like home, ‘home-cooked’ food and (generally) quiet and less frenetic atmosphere. These environmental, or functional, features were part of what made community hospitals feel ‘closer to home’. Being ‘closer to home’ increased the accessibility of community hospitals and went beyond convenience, through reducing the stress of travelling long distances or finding parking, through enabling frequent visits by family and friends and through representing an environment that was familiar, known, reassuring and nurturing, particularly for local patients and their families.
2. Interpersonal aspects of care also featured strongly in patients’ and carers’ narrative accounts – relationships between staff, patients and family carers were central to experiences of using community hospitals and so too were relationships between patients and the wider community. Patients highlighted the warm and welcoming staff, being looked after personally with sensitivity and respect, staff and volunteers spending time with them, being listened to, keeping their spirits up and time taken to care for the whole person, including multiple medical and social conditions. Instead of the depersonalizing patient experience associated with larger hospitals, reports of a much more ‘connected and reciprocal’ relationship between patients and staff were common; this is exactly what Bridges et al.³⁵ argue that we need more of.
3. Social aspects of patient experience were also highlighted, particularly the importance of having family and friends close by so that they could visit often – keeping families and communities together. The importance of the hospital being local, and community based, was stressed in terms of patients being known to staff and maintaining social connections during periods of hospital treatment, rather than being distanced and isolated. Social interactions between patients featured less in narrative accounts, but were facilitated to varying degrees in different hospitals through the utilisation of communal spaces for group dining and activity sessions and through the involvement of volunteers. For some, not enough was done to encourage activity and alleviate boredom (see Small et al.,²³ Payne et al.²⁵ and Trappes-Lomax and Hawton³¹ for similar findings).
4. Psychological aspects of patient experience were often wrapped up in their accounts of feeling less anonymous and frightened within their community hospital than they would in an acute setting and feeling more confident and hopeful, while also coming to terms with loss and change. Similarly, among family carers, the reassurance and reduction of stress associated with patients being cared for, often by people they knew, within a familiar, local community hospital were significant factors. On the other hand, this aspect also captured the shock and enormity of life events and psychological transitions that frequently coincided with patients’ use of community hospitals. Although community hospitals were generally seen to build patients’ confidence and physical health, a greater focus on psychological, emotional and mental health was needed.

When considered together, these four elements point to community hospitals as providing a relational (more human, caring, attentive), rather than transactional, model of care. Personal, reciprocal relationships between not just staff and patients, but between staff, patients, their families (predominantly referred to as carers within this report) and the wider community, and between all these people, the hospital services and their environments, were intrinsic factors in patients’ and carers’ experiences. This often contrasted strongly with patients’ and carers’ accounts of their previous experience of acute services. This relational model of care was facilitated through a closeness to home and community, for patients, their families and staff; the co-location and integration of a range of intermediate, generalist and personalised services; the small size, familiar and homely environment of community hospitals; and, as we shall discuss in more detail in the next section, their connection to and integration with the local community.

However, this highly valued relational model of care cannot be assumed or taken for granted. Although it was evident in all of the case studies, there were variations, moderated by a number of external and internal factors. Some of the developments currently affecting community hospitals, as outlined above (and in more detail in Chapter 4), were thought to pose a particular challenge to some of these highly regarded aspects of patient experience. In some, for example, the functional aspects of patient experience were challenged as facilities became dated, services were cut back or inpatients were drawn from an increasingly wide geographical area, meaning that community hospitals were no longer always local, convenient or easily accessible to all. The widening of geographical boundaries, and associated shifts towards greater provision of step-down care for increasingly elderly and acute patients, also had implications in some hospitals for the maintenance of the social and interpersonal aspects of care. In others, the interpersonal aspects were challenged by pressures on staff, exacerbated by recruitment challenges and a withdrawal of GPs from community hospital medical provision.

What does the community do for its community hospital, and what does the community hospital do for its community?

Community hospitals have a strong history of community engagement and support, often starting with raising funds to buy the land and build the hospital,¹⁰⁸ but until now there have been few attempts to empirically explore what communities do for their hospitals or vice versa. Whereas previous studies of community or voluntary support for, and engagement with, health-care institutions more generally have tended to focus on one particular form of support (e.g. volunteering, philanthropy or co-production), we looked more broadly at the different forms of support that were provided, to what level and to what effect. We found that communities support their hospitals in four key ways:

1. Giving time – volunteering was commonplace across community hospitals, particularly through the League of Friends, with each involving, on average, 24 volunteers, equating to between 1.4 and 2.5 full-time equivalent personnel per hospital. Volunteers undertook a range of roles, from fundraising through to befriending, campaigning and governance. Their efforts were mostly encouraged, co-ordinated and supported through Leagues of Friends, although in some community hospitals there was a significant amount of volunteering that took placed outside the League of Friends co-ordinated and managed by individual members of staff.
2. Raising money – community hospitals have been supported by financial donations and fundraising efforts within their local communities throughout their history. In 2014, on average, community hospital Leagues of Friends generated an income of £45,387 (median £15,632). Two-fifths of all income came from legacies, with the rest coming from a variety of activities ranging from domino nights, fêtes, running charity shops and providing day care services. Expenditure focused on supporting the hospital, patients and staff in a range of different ways, from providing patient comforts through to purchasing equipment, major building work and paying for staff time.
3. Providing services – the study shows that voluntary and community groups contribute to community hospitals through the provision of a wide range of services and activities, both within and outside the hospitals, for patients, their families or for the hospital in general. Some, however, thought that more could be done to further enhance partnership working between community hospitals and local voluntary and community groups.
4. Giving voice – despite a long history of involvement in community hospitals and active information and communication exchange through the Leagues of Friends, the mechanisms for and the depth to which communities are involved in decisions regarding their ongoing delivery and strategic future are generally limited. Overall, regular, ongoing engagement would likely be positioned towards the lower ends of the various spectra of participation (e.g. Arnstein¹⁰⁹): although information sharing and general communication was commonplace, engaging in consultations was periodic (and often frustrating) and meaningful redistribution of power through co-production relatively rare. Communities’ extensive voluntary support bought them no ongoing or privileged influence on decision-making, just as was the case in the pre-NHS voluntary hospitals.⁶⁹ This generated considerable frustration. These findings sit in tension with the strong sense of ownership that communities feel towards their hospitals.

Underlying these headline findings, we found considerable variations in the support that communities provided their community hospitals with. In line with wider studies on voluntary action, we found variations on three key lines:

1. Variations between community hospitals – there were considerable variations in the levels and forms of voluntary support between community hospitals. Whereas one of the case studies involved dozens of volunteers, for example, in a wide range of roles, another involved only one or two in a very limited capacity. Similarly, in common with many wider findings on philanthropy, this work reveals considerable variation in levels of charitable income between community hospitals. These variations were not easily explained in terms of, for example, community-level prosperity alone, but instead were influenced by the interaction of a range of factors that went beyond demographics to include the history of the hospital, of the community’s engagement with it, of local geographical characteristics including rurality and isolation and the range of services provided by the hospital.
2. Variations within communities – within-community variations were particularly notable in terms of regular, active volunteer involvement (including engagement in co-production activities). We found a tendency to rely on a small group of highly committed volunteers, many of whom had been involved for years. Although a wider group of community members offered more occasional support, the more active, regular volunteers were predominantly drawn from older age groups and were often women, with challenges identified in recruiting newer, more diverse participants. This raised concerns about future sustainability of involvement, particularly given that we also found that younger demographic groups identify less strongly with community hospitals.¹¹⁰ We agree with the conclusion of Munoz et al.⁵¹ that ‘harnessing more local volunteers . . . is more complex than governments assume’: we found a general lack of ‘investment’ in their recruitment, co-ordination or support outside that provided by Leagues of Friends or individual staff. Such investment is needed to sustain and support voluntary action, especially in an era of heightened expectations about the recruitment and conduct of volunteers.
3. Variations over time – we observed variations over time, particularly concerning voluntary income but also in membership and general patterns of engagement. Quantitative trend data were available only for voluntary income: since 1995, this suggests a steady decline in Leagues of Friends income, thus reflecting Clifford’s¹¹¹ findings on charity finances that identify several groups of charities for whom levels of resources have declined from the mid-1990s. However, we found little concern among the case studies regarding declining income. Instead, we heard more concerns about expenditure: spending money when the future of hospitals, their services or ownership were uncertain and/or about shifting boundaries between statutory and voluntary responsibility. We also found evidence that some of the hospitals continued to accrue funding even when they reduced their fundraising efforts because of, for example, concerns about the future of the hospital or so as to not overly dominate local fundraising endeavours. More generally, we heard that community support and engagement fluctuates over time in response to wider developments, such as policy and commissioning decisions, with activity (e.g. membership) peaks associated with services being perceived to be under threat, as well as to more local developments, such as changing personnel (hospital or League of Friends), that can serve to either encourage or discourage engagement.

These findings reflect broader thinking about the limitations of philanthropic effort, that is the variations in supply and the inability to match provision and need in a systematic manner.⁵⁹

Through these different forms of engagement, communities provide significant support (and, on occasion, challenge) to their community hospitals, leading to various outcomes for the different stakeholders involved:

• Patient experience – communities can positively affect patient experience, reflecting findings from Hotchkiss et al.,⁵³ Naylor et al.,⁴² and Kang and Hasnain-Wynia.¹¹²
• Service enhancement, utilisation and sustainability – they can also positively contribute to community hospital services by adding capacity, enhancing facilities and boosting staff morale, reflecting Mundle et al.⁵⁴ on the impact of volunteering in health services. They can also contribute to the resilience of community hospitals, through communication and promotional activities boosting utilisation and their campaigning, protesting and fundraising sustaining services that had been under threat of closure.
• Well-being and social capital – at the same time, although quantification is difficult (and beyond the scope of this project) and the evidence does not unequivocally state that volunteering always generates wider public benefits, in line with wider volunteering literature,¹¹³ we found that individual supporters (especially volunteers) and communities more generally can themselves benefit through, for example, the development of skills, networks, trust and reciprocity.

In doing so, the voluntary support that communities provide to their community hospitals adds to and, indeed, is an integral part of the social value of community hospitals, as we discuss further below.

None of these forms and levels of engagement, or their positive outcomes, however, can be taken for granted. The study suggests that a lack of appropriate support for volunteering, for example, may lead to volunteers doing too much and risking burn-out, reducing the benefit to patients and putting a strain on relationships with paid staff. Recruiting new, younger volunteers can be difficult, while membership and voluntary income levels are both on the decline, and concerns about the appropriate role for voluntary support within statutory services were expressed. Furthermore, echoing research elsewhere,^51,114 there are capricious variations in the extent of voluntary support that cannot be simply explained by any one factor. Converting the extensive passive support found across communities into more regular, active engagement requires investment of time, energy, enthusiasm and, inevitably, money.

The other half of our question (‘what do community hospitals do for their communities?’) addressed an evidence gap in relation to the social value of community hospitals.^22,64 This study suggests that community hospitals can fulfil a number of important functions for the communities in which they are embedded and can provide significant added value. Community hospitals can represent a significant community asset, with an associated strong sense of community ownership. Their provision of local, accessible health and social care services has an important practical social and symbolic significance, particularly in the more isolated rural communities, and, as established institutions known to generations of the same family, they are integral to a sense of community identity, pride, belonging, reassurance and security. The engagement of communities in the community hospitals, as discussed above, is an important element of their added social value.

Adapting and expanding the framework devised by Prior et al.⁶⁸ and developed by Farmer et al.,⁶⁴ we found that the ‘social value’ of community hospitals, at collective (family, community) and individual (patient, carer, staff, volunteer, resident) level, can be disaggregated into six distinct forms of value that, together, can be conceptualised as ‘community value’. The study was not designed to measure any of these quantitatively, but interviewees identified each to be significant and important:

1. Instrumental – through the provision of local, accessible, integrated, intermediate health and social care services, associated with highly regarded patient experience.
2. Economic – through the provision of local, high-quality, valued jobs, the reduction of travel costs associated with accessing more distant health-care services and through the encouragement and support of agriculture, tourism and in-migration and the viability of other services.
3. Social – through the development of networks of interaction, trust and reciprocity, built directly through the services provided by the community hospital and indirectly through the community engagement activities that support it.
4. Human – through the creation of jobs and volunteering opportunities for local people that involve skills development and utilisation and can enhance confidence, morale and well-being (of staff, volunteers and patients).
5. Cultural – community hospitals can have cultural value, through contributing to a sense of individual (especially for staff and volunteers) and collective identity, feelings of belonging and civic pride and a collective sense of place (see James,¹¹⁵ Farmer et al.,⁶⁴ Gesler¹¹⁶ and Kearns and Joseph¹¹⁷ for similar findings).
6. Symbolic – as a symbol of vitality and viability of the community (see Liu et al.⁷⁰ and Lepnurm and Lepnurm¹¹⁸), community hospitals contribute to perceptions of resilience and autonomy. More profoundly, they can provide a sense of security and safety individually, for patients and their families, and collectively for the wider community, thus supporting Jones’s⁶⁶ suggestion that hospitals might contribute a deep sense of reassurance to the communities in which they exist. This symbolic value is absent from previous frameworks, although referred to within wider discussion.^64,68

Overall, community hospitals are an important community asset. Their value comes not only directly and indirectly from their physical presence and service provision but also through the different forms of engagement that they inspire: the process of actively supporting community hospitals (e.g. through volunteering and fundraising) further enhances their value. Although previous studies have suggested a link between the history of place, hospital, health and community through the study of individual cases (e.g. Andrews and Kearns¹¹⁹) or in other countries (e.g. James¹¹⁵), this study is the first to demonstrate these findings across multiple community hospitals in England.

What does ‘community hospital’ mean?

Although we started by posing the question ‘what is a community hospital?’, this question has developed to become ‘what do community hospitals mean?’. This enables us to capture the depth of feelings and significance often expressed by the patients and carers who use them, the staff who work in them and the individuals and communities who support and value them – among whom there is much crossover. It is only by combining the understandings that emerge from addressing each of the three individual study questions, and seeing the connections between them, that we come to new insights into the meaning of community hospitals. As Higgins¹²⁰ suggested, small (community) hospitals mean more to communities than simply a place to receive health care. We highlight three particular, inter-related, meanings.

1. Community hospitals mean locally embedded, integrated, intermediate, generalist care (see also Heaney et al.²² and Pitchforth et al.¹) that brings together not just primary, secondary and community health care and health and social care, but also statutory provision with voluntary and community ‘provision’ within one accessible location. The existing and potential significance of community hospitals as sites of integrated intermediate care was widely recognised, with considerable enthusiasm for further expansion of the range of services they provide as ‘hubs’ at the heart of their communities.
2. Community hospitals mean embedded, relational care. The relational model of care, which we outlined above, stems from the embeddedness of community hospitals within their local health-care systems and, more fundamentally, within the histories, cultures and social networks of the communities and places within which they are anchored (Figure 15). Understanding the significance of the interdependent, reciprocal or mutually reinforcing and beneficial relationships between individual patients and families, their hospitals and their communities is an important step forward in recognising not just what community hospitals are, but also how they are experienced and valued and what they mean. Through actively supporting their hospitals, for example, community members can help boost staff morale, which, in turn, can have a positive influence on patient and care experience, which, in turn, can help boost active community support.
3. Community hospitals mean a deep sense of reassurance and of ontological security,⁶⁷ as Jones⁶⁶ suggested they might. This reassurance comes, in part, from the physical presence of a community hospital, which acts as a visible expression of both historic and contemporary collective care and identity, but also from the different forms of interaction with it and the sense of ownership that this inspires. It extends beyond individual patients and their families to staff and, significantly, to the communities in which they are based, and it connects together the different forms of value that community hospitals represent to these different stakeholders.

FIGURE 15

An embedded, relational model of care.

These meanings, however, vary between communities. Community hospitals, for example, vary not just in their orientation towards primary or acute care, but also in their embeddedness within the communities within which they are situated. Both orientations make a difference to patient experience, community engagement, value and meaning. If, for example, community hospitals become disconnected from their communities, not only do they risk losing out on the direct benefits of community engagement, but they also risk weakening the relational model of care that currently defines them, reducing their community value.

Meanings also vary within communities, influenced by factors such as age, health, duration of residence and personal connection. In general, community hospitals mean more to those who have direct contact with them than to those who do not: whether as patients, family or friends of patients, staff, volunteers or more distant supporters. For many community members, they may become aware of their local hospital only during moments of crisis. Furthermore, despite the significant value and meaning that community hospitals represent for their communities in general, this translates into regular, active and sustained engagement for only a relatively small and selective group of people.

There is also variation over time. This research has highlighted the dynamic nature of community hospitals (see also Pitchforth et al.¹ and Heaney et al.²²) and their susceptibility to change as a result of both internal and external developments that have contributed to their current diversity and, arguably, to their agility and resilience. These changes potentially shift the meaning of community hospitals.

The current context of austerity, an ageing population and increasing pressures on health-care services overall, combined with a lack of national strategy for community hospitals, are putting them under pressure and pulling them in different directions without any clear steering mechanisms. The withdrawal of GPs, the shift towards step-down care, the delivery of services to a wider geographical area, the associated increasing acuity of inpatients and questions over the future of community hospital beds are particularly visible demonstrations of these pressures. Together, they have the potential to shift not just the characteristics, function and patient experience of community hospitals, but also their community value and meaning. We found examples among the case studies when the hospitals had changed/were changing to such an extent that community members felt that they were no longer providing local services for local people by local people, which in turn led them to withdraw their active support and, in turn, led them to question whether or not they could still be considered ‘community hospitals’. Their meaning had been lost: they were no longer embedded, relational or reassuring, but were simply intermediate care units based in the local area.

Within this challenging context, questions arise as to how both patient (and carer) experience and community value are taken into account when making decisions regarding the future of community hospitals. Harlock¹²¹ identified the challenge of embedding social value in commissioning processes in general. Many of this study’s respondents, outside the commissioning process, argued strongly that neither community value nor patient experience was taken fully into account and that, instead, cost was the over-riding consideration. It was felt that patient experience could be dismissed as undiscerningly positive and community value dismissed as an innate resistance to change and/or a naive understanding of the cost and value of community hospitals.

Implicit within these discussions is an inherent tension within community hospitals: they are not bounded entities with discrete, matching ownership, management and governance structures to steer and direct them. Although communities, and indeed many patients and staff, feel a strong sense of ownership towards community hospitals as whole entities, they rarely retain legal ownership or have a significant say in their strategic direction through formal governance or management structures. Furthermore, with the relatively recent proliferation of providers operating within them (stemming from the 2012 Health and Social Care Act),¹²² there is a lack of ‘overall control’ for individual community hospitals as whole entities rather than as collections of services, the management and governance mechanisms for which extend beyond either hospital or community. This seems a unique and particularly challenging feature of the community hospital sector.

There have been threats to these institutions in the past. The Ministry of Health’s 1962 Hospital Plan⁷ proposed the closure of numerous community hospitals, but a combination of community opposition, changing views as to the nature of general hospital provision and economic circumstances meant that many survived and new visions came to be articulated of the contribution that community hospitals might make. Within the current context of STPs (now Sustainability and Transformation Partnerships), there is a concern that the localised approach to their development may obscure their combined effect on community hospitals across the country, limiting the potential for local voices to be heard at national level.¹⁹ The attractiveness of proposals for new models of care focused on supporting patients in their own home, while also making financial savings elsewhere in the system, is likely to sideline the potential role for community hospitals to provide a range of services ‘closer to home’ (in the different ways that we have demonstrated this to represent), let alone their wider social value. A lack of authoritative guidance for the NHS as a whole,¹⁹ combined with a lack of hospital-level governance and management mechanisms that involve local stakeholders, could leave individual community hospitals vulnerable to financially driven decision-making processes. Although some areas have recognised and reinforced the role of community hospitals within their STPs, many appear to be looking to reduce provision and/or to move away from a model of community hospitals with inpatient beds to one of community hubs with an extending range of services but often no inpatient beds. Although an expansion of services is likely to be welcomed by many communities, a closure of beds or a threat to their community hospital is not.

Evidence from elsewhere suggests that community hospital closure can be a ‘critical incident’ for rural communities,¹²³ mobilising extensive support¹²⁰ motivated by a desire to preserve and protect the hospital. This can represent both significant challenges for commissioners and providers and a significant opportunity. It offers the potential to harness the passion and pride that communities feel towards their hospitals and build on the highly valued embedded, relational model of care experienced by patients. It provides an opportunity to realise the potential identified by Pitchforth et al.¹ for community hospitals to assume a more strategic role in health-care delivery locally, providing care closer to people’s homes or, more ambitiously, as recognised by at least one case study, to put community hospitals at the heart of new models of population-based health and social care.

Key contributions

For all the longstanding (and sometimes controversial) debates that there have been around the role and future of community hospitals in England, it is remarkable that, until now, we have lacked:

• a widely accepted definition of community hospitals and a definitive understanding of the number, location and services provided
• a detailed understanding of patient experience
• an understanding of the relationship between community hospitals and their local communities.

At a time when many areas are disinvesting in community hospitals (particularly in bed-based services), but when others are investing in an expansion of such services, it is difficult to see how either of these directions of travel can be evidence based given the very limited nature of current knowledge. That we know so little about such a longstanding feature of the NHS (and pre-NHS health care) is perhaps itself a symbol of neglect, and remains a significant concern given current debates about the future of a number of community hospitals, and the very strong public reactions that these debates provoke, in a challenging policy context.

Against this background, we believe that this study is the most detailed, comprehensive and robust analysis of the characteristics and value of community hospitals that there has been for many years (perhaps even in the history of the NHS), with the subsequent data shared with community hospitals themselves and made publicly available as a resource for the CHA, local services, commissioners and policy-makers alike. In particular we have:

• Developed a new typology of community hospitals and produced a publicly available database of current community hospitals, their size and location, their services and key activity data. As described in Chapters 2 and 3, this has significant advantages compared with previous attempts to capture such information, producing the most comprehensive and detailed data ever compiled. This was significantly aided by the ability to combine the experience of working with national data sets with the detailed local knowledge of the CHA (essentially, a ‘top down’ and a ‘bottom up’ way of understanding the nature of community hospital services). This process has revised previous assumptions around localness, small population base and primary care leadership and contributed to a new typology for understanding the orientation of community hospitals.
• Generated in-depth data on patient experience that contrast strongly with participants’ prior experience of acute care. This not only fills a significant gap in the literature but has also enabled us to propose a new model for analysing patient experience based on the functional, social, psychological and interpersonal aspects of care and to conceptualise community hospitals as providing embedded, relational care.
• Produced unique insights and data into community engagement and community value, combining the best of the health services management and voluntary sector research expertise of the current team. Such data are patchy/rare for most health services, but are almost non-existent for community hospitals. This has allowed us to understand the breadth, depth and variability of community engagement and to adapt and extend the framework proposed by Prior et al.⁶⁸ and Farmer et al.⁶⁴ to consider the contribution of community hospitals in terms of the economic, social, human, cultural instrumental and symbolic value that they represent at individual and collective levels. Asking what a hospital does for its community and what a community does for its hospital are highly significant questions in the current context (both academically and in policy terms), and it seems remarkable that such questions have rarely been explored in depth before.
• Moved beyond discussions of what community hospitals ‘are’ or ‘do’ to more fundamental questions about what they ‘mean’; this is significant academically, but also in terms of current debates about the configuration of health services in a challenging financial context and, particularly, how concerns for patient experience and community value are taken into consideration, alongside the domination of cost efficiencies.

Limitations of the study

The mapping exercise within work package 1 was limited to those community hospitals with beds. This is consistent with our provisional and final definition, but we are aware that others might wish to include some other local sites under the umbrella of community hospitals. Furthermore, the cross-sectional nature of the mapping exercise combined with time delays within our data collection and analysis of the NHS Digital database (which was collected in 2012/13 and validated against data current at 2015) means that our finalised list will subsequently have become outdated following hospital closures and other changes to hospital function.

The site of treatment code used to identify community hospitals within the NHS Digital data is not stable or complete: it is organisation based and changes each time the NHS restructures. The need to investigate 60 potential sites that were not visible in the NHS Digital data set highlights the limitation of site of treatment code, which, in a minority of cases (< 10%), may be set at a level that is more aggregated than community hospital (e.g. trust level).

The investigation of patient experience (work package 2) was intended to include an equal sample of inpatients and outpatients/clinic patients, but this did not prove possible, with the resulting patient sample skewed towards inpatients. As such, the experiences we report are more reflective of inpatients than of all patients and this is reflected in the presentation and analysis of results.

In analysing data on the uses of funds raised by the communities for their hospitals, there are limitations to the Charity Commission data. Only in those cases in which a League of Friends (or its equivalent) has an income of > £25,000 do we have any detail at all about expenditure beyond an aggregate figure, and variations in recording of this between hospitals, plus the degree of generality of the terms used in accounts (e.g. terms, such as ‘charitable activities’, with no further detail), limit what we can say. We also lack information that would help us understand the financial position of charities in more depth, such as their reserves.

In exploring questions of community engagement and value, the case studies were limited by the focus on respondents who had some form of connection with the hospital, or who at least had a significant role within the local community. Practical limitations meant that we were unable to extend our sample to general members of the public with no connection to or involvement in the hospital at all.

Implications

Recommendations for future research

• Compare and contrast patient experience and outcome of those supported in acute hospitals, in community hospitals and in their own home. This is particularly important in the current context with the drive for new models of care that look to optimise the level of home-based care.
• Longitudinal studies of community engagement (including historic) with local health services, how this varies between different types of service provision (e.g. acute, community), how it is changing over time, how the boundary between statutory and voluntary support is shifting and the implications of all of this.
• Longitudinal research with community hospitals to explore the ways in which they are evolving, particularly the change in clinical leadership and practice associated with the withdrawal of GPs, but also the development of hubs without beds and the effect of such changes on patient experience, community engagement and value.
• An international comparative study on inpatient case mix in community hospitals, examining levels of dependency, acuity and complexity to establish reasons for admission, diagnosis, outcome and discharge destination.