Analysis of the profile, characteristics, patient experience and community value of community hospitals: a multimethod study

Environment and facilities

Many previous studies of community hospitals focused on the functional aspects of care, asking patients to give feedback on, for example, access to services, the quality and range of facilities and equipment, the environment and atmosphere, and levels of cleanliness.

Patients in these studies valued a close proximity to family and friends when using community hospitals, as well as the opportunity to interact with patients from the same geographical location,23–26 the homely and friendly atmosphere,24–26 the orientation to older people,27 the level of cleanliness,24,25,28 the availability of single-room accommodation,23,24,29 and the quality, choice and presentation of food. 23,24,29,30 However, some patients felt that community hospitals could be noisy environments23,26 and others reported long periods of boredom. 23,25,31 Few studies appeared to go on to explore how these environmental factors affected patients’ experiences of care.

Delivery of care

Several studies also focus on the technical aspects of care. Community hospital inpatients were often satisfied with their care, comparing this favourably with experiences in acute care,24,32 and valuing greater continuity of care,24,25 information sharing23,26,33,34 and the potential for longer lengths of stay. 26,29,31,35 However, rehabilitation and ongoing needs were reported as not always being met on discharge. 31

Staff

A subset of these studies also focus on the more relational aspects of care. Community hospital staff were often perceived more positively than those at district general hospitals (DGHs); they were experienced as being kind, caring, friendly, knowledgeable and committed to seeing people as individuals. 23–26,29,32 However, at times, patients lacked confidence in the technical skills of some staff,25 preferring to go to an acute hospital when requiring more complex medical expertise. 26

Notwithstanding these insights, the evidence base remains underdeveloped and focuses primarily on the functional and technical aspects of care. Bridges et al. 35 argue that patients’ and relatives’ narratives rarely focus on the functional or technical aspects of care. Instead, they often relate to the more relational and interpersonal aspects of their experience. Similarly, our previous research into older peoples’ experience of moving across service boundaries36 found that, although health and social care services often focus on the physical aspects of transition (e.g. relocating from one setting to another), older people tended to talk about transition in terms of the psychological (e.g. changes in their identity or sense of self) and social (e.g. changes in their relationships with partners, family and friends) impacts.

These insights from, and gaps within, the existing research, combined with a concern for what matters to patients and how that is understood and represented, shaped the aim and methodological approach of work package 2, which addresses the question: what are patients’ experiences of community hospitals?

Forms and levels of voluntary and community support

A key gap in the literature is empirical analysis of voluntary and community support for community hospitals in England. Hospital Leagues of Friends (the main conduit of such support) have been the subject of only one published UK academic study. 41 Existing national survey evidence does not allow for the identification of health-related voluntary activity in anything but the most general terms. 42

Broader research on engagement with other health settings gives an indication of the significance of voluntary support in the field. Naylor et al. 42 estimate that approximately 2.9 million people regularly volunteer for the health sector as a whole in England. The study by Galea et al. 43 of NHS acute trusts in England found that, on average, they involve 471 volunteers, making a total of 78,000 people who together contribute a total of 13 million hours per year. Volunteers undertake a considerable range of roles – as many as 100 – within NHS hospitals. 44 Naylor et al. 42 note that volunteers are increasingly involved in both strategic roles and roles that involve direct patient contact.

Previous studies of voluntary income for the NHS or other specific subsectors of health care45 have focused on relatively large organisations or have used data at the level of District Health Authorities, meaning that levels of support for individual institutions cannot be identified. 46

Engagement patterns and variations

Evidence on specific patterns of engagement within community hospitals is very limited. Historical evidence of voluntary income for the pre-NHS period hospitals, however, suggests that considerable variations may well persist. 47,48 More generally, national surveys of volunteering show that rates and levels of volunteering differ by socioeconomic status, employment status, age, strength of religious affiliation, ethnicity, disability and region. 49 Mohan and Bulloch50 report strong social and geographical gradients in voluntary activity and identify a ‘civic core’ delivering the bulk of voluntary effort. Prosperous, well-educated, middle-aged population groups dominate the civic core. 51 These studies suggest that voluntary support for community hospitals might be expected to vary between and within communities. Such national samples, however, cannot provide detail on voluntarism in individual types of organisation (such as community hospitals) and on the nature of voluntary activities within them.

The outcomes and impact of voluntary support

Describing different forms of voluntary support or counting the numbers of volunteers or the levels of voluntary income raised will give a measure of activity, but not of difference made. It is also important to consider the outcomes of such activities, such as contribution to patient experience and/or the quality of services in the hospital. This moves us to a level of considering and assessing impact and value. Direct or intended outcomes, for example, may include enhanced patient experience. Indirect, or unintended, outcomes include whether or not community engagement has wider spillover for the community in the form of raised levels of social capital, for example (elsewhere we refer to this as latent value). Unfortunately, capturing outcomes, impact or value is by no means simple. Although some elements lend themselves to quantification (e.g. funds raised, numbers of volunteers recruited), others are harder to identify and rely on self-reports by stakeholders, who may not be without their own interests and biases.

A small number of studies have considered the outcomes of certain forms of community engagement for hospitals and for the wider health-care system. There have, for example, been some attempts to measure the financial value of volunteering to individual hospitals, although with considerable limitations. 52,53 The qualitative research of Naylor et al. 42 with volunteers, patients, commissioners and service providers, and the Mundle et al. 54 review of literature on volunteering in health and social care both found that volunteers have a positive impact on health and social care systems in a number of ways. Identified impacts included improving the experience of care and support, strengthening the relationships between services and community, improving public health and supporting integrated care. The findings of another study, however, somewhat contradicted this: Milton et al. 55 found no existing evidence of positive impact on population health or quality of health services and failed to identify any studies that had attempted to determine the impact of community engagement on wider health outcomes.

There is even less evidence of the impact of such activities in community hospitals (or health-care services more generally) on the wider community. Indeed, there is very little evidence of the outcomes of volunteering on communities more generally, beyond general suggestions that volunteering contributes to community-level social capital development, which, in turn, contributes to community vitality, sustainability and resilience. 56 None of these focus specifically on the outcomes and impact of voluntary support in/through community hospitals.

Finally, distributional effects require attention. As noted above, underlying theories of voluntary action predict that its distribution (whether expressed in terms of funding or volunteering) will reflect variations between communities in resources, the availability of leadership and the idiosyncratic preferences of donors, rather than a needs-based allocation of resources. 57,58 How these processes work out is a contingent matter. Voluntary effort and charitable giving are known to be capricious and unpredictable. Salamon59 articulates four weaknesses: (1) philanthropic insufficiency (and variability), (2) paternalism, (3) amateurism and (4) parochialism. As levels of forms of voluntary action in community hospitals are likely to vary, so too are its outcomes.

The social value of community hospitals

Although it is often assumed that community hospitals are important to their local communities, the specifics of this relationship are under-researched. There have been many assertions recently about the concept of ‘social value’, particularly in relation to public service reforms and following the Public Services (Social Value) Act 2012,60 which enjoined commissioners of public services to take account of ‘economic, social and environmental wellbeing’ when placing public service contracts. With an increasing emphasis on outcomes-based commissioning, a consideration for the social value of a service offered the potential to move beyond purely financial considerations. As Dayson61 notes, however, ‘what constitutes social value and how to measure it is contested’. Citing Phills et al. ,62 Dayson goes on to suggest that ‘social value can be described as the benefits created for society through efforts to address social needs and problems’; these benefits, or values, may be economic, social or environmental and may be experienced by certain individuals, groups of individuals or society as a whole. 63 Social value is not exclusively associated with a particular organisational form, but there has been a strong association with voluntary organisations through the suggestion that the voluntarism and pro-social motivations for behaviour within such organisations add value to their activities.

There is little existing evidence on the social value of community hospitals to the communities in which they are based. More generally, however, wider literature points to the significance of hospitals and other institutions to communities, and rural communities in particular, as a source of collective identity and in contributing to a sense of place. 57–59,64 Research from New Zealand65 found small hospitals to be a source of civic pride and security and a symbol of legitimacy. Jones66 proposes Giddens’s67 concept of ‘ontological security’ as a way of understanding the ‘deep sense of reassurance’ that hospitals contribute to the communities in which they exist.

Developing these ideas further, Prior et al. 68 presented a typology (subsequently further developed by Farmer et al. 64) of the ‘added-value’ contributions of health services to remote rural communities at institutional and individual level, incorporating economic, social and human capital.

History provides a guide as to why such community attachment is important. In the pre-NHS era, although competition between doctors in a crowded medical marketplace also drove innovation, many hospital foundations were originally motivated by community needs, and the memorialisation of those fallen in war was also significant. Thus, symbolic value was inbuilt from the outset. Nationalisation did not quell the fires of attachment, with many Leagues of Friends established within a few years of the establishment of the NHS in 1948. The flames of community resistance were fanned by proposals for centralisation, as described by Mohan’s69 analysis of the 1962 Hospital Plan for England and Wales and the associated resistance to closures; it is hardly surprising that when hospitals had been established largely by local voluntary effort, proposals to remove them by the state would be fiercely resisted.

Broader social changes may plausibly be said to be associated with attachment to local hospitals: as the fabric of communities thins out (e.g. through closures of major employers) and as community ties are weakened (e.g. by longer commuting patterns) then mobilisation for remaining institutions becomes more important; international studies confirm this, particularly within the context of hospital closures. 70

In response to gaps in the knowledge of the role that voluntary and community action plays in supporting community hospitals, and that community hospitals play in their local communities, the aim of work package 3 was to undertake robust and systematic quantitative and qualitative research to address the research question: what does the community do for its community hospital, and what does the community hospital do for its community?

Literature review: constructing a working definition

We developed a working definition of a community hospital as drawn from the literature (and as outlined in Chapter 1):

• A hospital with < 100 beds serving a local population of up to 100,000 and providing direct access to GPs and local community staff.

• Typically GP led, or nurse led with medical support from local GPs.

• Services provided are likely to include inpatient care for older people, rehabilitation and maternity services, outpatient clinics and day care as well as minor injury and illness units, diagnostics and day surgery. The hospital may also be a base for the provision of outreach services by MDTs.

• Will not have a 24-hour A&E nor provide complex surgery. In addition, a specialist hospital (e.g. a children’s hospital, a hospice or a specialist mental health or learning disability hospital) would not be classified as a community hospital.

The initial enquiry was framed around a ‘classic’ community hospital. The term was drawn directly from the Community Hospital Association 2008 classification,72 describing classic community hospitals as ‘local community hospitals with inpatient facilities’ (i.e. with beds) and as distinct from community care resource centres (without beds), community care homes (integrated health and social care campus) or rehabilitation units. Although the term ‘classic’ was initially helpful in setting the boundaries of the study, it presented ongoing problems, such as whether it described all community hospitals with beds or a subset within that. Throughout the study, therefore, we have adopted the term ‘community hospital’ and omitted the adjective ‘classic’. Our focus, however, has remained on community hospitals with beds.

Data reconciliation: building a new database from multiple data sets

There was no up-to-date comprehensive database of community hospitals in England. The NHS Benchmarking Network [URL: www.nhsbenchmarking.nhs.uk (accessed 8 October 2018)] membership database was not comprehensive and could not be used to populate our hospital-level database because the data were anonymised. For this reason, one of our first tasks was to compile a new database, by bringing together existing health-care data sets, each of which provided different fields of information needed to test our working definition and to map and profile community hospitals.

Two types of data sets were collected. Centrally available data sets formed the starting point for the mapping study, providing codified data (see Appendix 1). As none of these centrally available data sets provided a comprehensive picture, it was necessary to supplement them through extensive internet searching and by talking to people in the field, as well as drawing on the expertise of research team members.

The base year for major data sets was 2012/13. Data were difficult to access, not comprehensive and spread across a greater number of sources. Four data sets were used:

1. Community Hospital Association databases of community hospitals (one from 2008 and another from 2013)

2. Patient-Led Assessments of the Care Environment (PLACE) 2013 [replacing the former Patient Environment Action Team programme]

3. Estates database – Estates Returns Information Collection (ERIC) 2012

4. NHS Digital activity by site of treatment 2012/13.

Barriers to obtaining site and activity data included (1) specific difficulties in the period 2012/13 when primary care trusts (PCTs) were being disbanded and clinical commissioning groups (CCGs) were being established (with effect from 31 March 2013) and (2) processes and caution in NHS Digital associated with releasing patient-sensitive data (even though we had not requested patient-based data). Quality problems were associated with the ‘location of treatment’ code, which was central to our enquiry identifying community hospitals but did not appear to be well used in England, leading to examples of missing data and inconsistent labels (described under reconciliation and duplication). The code also lacked stability as it changed with each new NHS reconfiguration in England.

The core data set for England, supplied by NHS Digital, was a list of all hospitals in England, based on ‘site of treatment code.’ Figure 2 shows the relationship between national data sets.

FIGURE 2.

The relationship between four England data sets. CHA, Community Hospitals Associations.

The new database, populated through our reconciliation of these various data sets, provided a census of community hospitals at 2012/13, which was updated to August 2015 (e.g. when a hospital closed and then redeveloped, formed a new hospital replacing two old community hospitals, closed beds on a temporary basis and changed its name).

Database analysis: developing an initial classification of community hospitals with beds

Although the focus of this report is on England, it is important to mention our work on mapping community hospitals in Scotland, as this was instrumental in developing our approach to classifying data for England. Data sets on community hospitals in Scotland [Information Services Division (ISD) and government community hospital data sets: community hospital, general hospital, long-stay/psychiatric hospital, small long-stay hospital] were both more accessible and more comprehensive, lending themselves to early analysis (see Appendix 2).

An initial classification of hospitals in England was developed, informed by categories set out by Estates (community hospital, general acute hospital, long-stay hospital, multiservice hospital, short-term non-acute hospital, specialist hospital, support facility, treatment centre) and PLACE (acute/specialist, community, mental health only, mixed acute and mental health/mental health, treatment centre). It was combined with specialty classifications based mainly on NHS Digital inpatient activity data and developed further through analysis of Community Hospitals Association (CHA) data and discussions within the study team (Table 2).

Rapid telephone enquiry: refining the classification

Analysis of the Scotland data suggested that the code ‘GP specialty’ was a defining feature of community hospitals, but early analysis of the England data showed that this was less transferable. If we relied on GP specialty coding alone, many known community hospitals would be excluded from our database: not all community hospital inpatient beds in England were coded to GPs.

A short piece of empirical data collection was undertaken to understand the link between the specialty codes and practice and to test the working definition (based on the literature and on the Scottish data) that community hospitals were predominantly GP led. A telephone questionnaire was designed by the study team (see Appendix 3) and piloted through the CHA.

Seven hospitals from five specialty category codes (≥ 80% GP, < 80% GP and mixed specialties, general medicine, geriatric medicine, geriatric mixed specialties) were randomly selected. The test sample of 35 was reduced by four as a result of closure or conversion to nursing homes. The research team called the hospitals to gain contact details of the matron or ward manager (n = 20; the small sample size highlighting the difficulty of identifying leadership, especially when the community hospital is represented by a single ward), e-mailed the questionnaire, conducted telephone interviews with staff to complete the questionnaire (taking 10–20 minutes each), transcribed notes and returned the completed questionnaire to respondents (n = 12). Analysis of these telephone interviews gave us confidence in the specialty coding, while also confirming the need to be more expansive in our working definitions and categorisations.

Verification: checking and refining the database through internet searches

The mapping enquiry was finalised through five iterations of searching and checking. The CHA consulted its database and membership list (from both 2008 and 2013). A full internet search took place at two points, in February 2015 and August 2015, taking account of hospital closures and changes of function up to 2014/15, with further validation and amendments up to August 2015. By the end of the study, the 2012/13 data set, based on the NHS Digital Spine using ‘site of treatment code’, had been validated through a check of every potential community hospital. A total of 366 sites were examined through web-based and telephone enquiries, including 60 that were not present on the NHS Digital database (see Appendix 4 for the list of community hospitals with beds).

Selection of case study sites

In selecting case study sites, we adopted a ‘realist’ approach to sampling,79 moving back and forth between categories identified from the literature as being important for patient experience and community value and our learning about the characteristics of community hospitals identified from the mapping exercise. In order to reflect the diversity of community hospitals (highlighted in the literature and mapping), we selected cases in contrasting locations with different numbers of beds, ranges of services, ownership/provision and levels of voluntary income and deprivation.

To allow for a particular focus on variations in voluntary support for community hospitals, hinted at through the national mapping exercise and identified as a particular gap in the existing literature, we selected pairs of hospitals across four Clinical Commissioning Group (CCG) areas with contrasting levels of voluntary income but similar levels of deprivation. This would allow for a good comparison within and between cases (e.g. why two community hospitals within one CCG area, with similar levels of deprivation, have contrasting levels of voluntary support, given that previous research has tended to suggest a strong negative correlation between deprivation and voluntary activity).

Using these criteria, we selected eight case studies of hospitals of different sizes, ages and service profiles located across England (although mostly concentrated in the south, reflecting the national pattern of community hospital development; see Figure 7) in areas of contrasting levels of deprivation. Six of the buildings were owned by, and their main inpatient service was provided by, the NHS. Two were owned by the NHS but their main inpatient services were provided by a community interest company (CIC). We added a ninth case study, owned by a charity, to increase diversity in terms of ownership/provision (as there were very few examples of independently owned community hospitals, it was not possible to identify a matched pair). Table 3 provides a summary of the nine case studies selected, according to the data that were available from the mapping exercise. Fuller qualitative descriptions are provided in Chapter 4 and Appendix 5.

Case study data collection

The case studies involved seven research elements, as summarised in Table 4. All elements were conducted over five visits to each case study. Across all case study sites and research methods, 241 people participated in the study through interviews and 130 people participated through 22 focus groups; a small number of people who participated in individual interviews also participated in focus groups (see Appendix 6 for full details).

Qualitative case study data analysis

We adopted a thematic approach to qualitative data analysis, aided by the use of NVivo 11 (QSR International, Warrington, UK) for data management and exploration. Our approach was both inductive, with themes emerging from the data, and deductive, framed by our research questions and ongoing reading of the literature. Initial themes and codes were developed after three members of the team (AEP, DD and NLM), who collectively had been responsible for the case study data collection, reviewed the transcripts. The emerging themes, codes and associated findings were discussed at wider study team meetings, at the LRG meetings for individual case studies and at annual learning events that brought together participants from across the case studies. A refined coding frame was then tested by the same three members of the research team each coding a sample of transcripts; this led to a further refinement of the codes, while also helping to ensure that each of the researchers was adopting a similar approach.

In this report, we focus in particular on across-case comparisons, highlighting themes that emerged across the case studies, emphasising key points of similarity and difference between the cases, as relevant. In addition, we have produced individual reports for each of the local case study sites that have shared findings from our within-case analysis, as relevant for each individual hospital. Comparative analysis, including of the paired cases, will be developed further in future research articles, in which a focus on more specific aspects of the study will allow more space for presentation of such work.

Throughout the analysis, unique identifiers were used for the transcripts/respondents to help ensure confidentiality and anonymity. Sites were assigned a number (e.g. CH1) and respondents given a letter: patient (P), family carer (CA), staff (S), volunteer (V), community stakeholder (CY) and senior manager or commissioner (T), with sequential numbering, date of interview and initials of researcher added to provide an audit trail. This basic coding method is used throughout the report (e.g. CH1, S01 represents the first staff member to be interviewed at the first community hospital case study site). It is worth noting, however, that, although respondents were identified by a key characteristic (e.g. patient or staff) and their transcripts labelled as such, the boundaries between these categories were not discrete: many community stakeholders, for example, had also been patients or carers, and many staff were also members of the local community.

Collating data on charitable finance and volunteering support

The third phase of our research involved the quantitative analysis of data from the Charity Commission on voluntary income and volunteering for community hospitals across England. The aim of this activity was to examine charitable financial and volunteering support for community hospitals by investigating:

• variations in the likelihood that hospitals receive support through a formal organisational structure such as a League of Friends, and if so, variations in its scale (in financial terms) between communities

• uses of the funds raised (e.g. capital development, equipment, patient amenities).

We captured financial and volunteering data for registered charities from the Charity Commission (the Commission). The Commission holds details of organisations that have been recognised as charitable in law and that hold most of their assets in England, or have all or the majority of their trustees normally resident in England, or are companies incorporated in England. The data are described more fully in Appendix 9.

Subject to a small number of exceptions, all charities in England with incomes of > £5000 must register with the Commission and submit financial statements consisting of trustees’ annual reports (returns) and annual accounts. The accounts of those charities whose income or expenditure exceeds a threshold of £25,000 are made available on the Commission’s website. 89 Charities that have income and expenditure of < £5000 a year have (since 2009) been exempted from the need to register. We identified 274 hospitals in England that satisfied the inclusion criteria for this research project (Figure 3). We used the Charity Commission’s data to identify charities that support each of these hospitals, matching by name or through examining lists of charities registered in the locality where the hospital is based.

FIGURE 3.

Community hospital and charities sampling frame.

We also directly approached eight non-registered charities (usually those with an income of < £5000 a year) that were known to have been established to support specific community hospitals, but received no usable data relating to them. Four hospitals in our data set were registered as charities themselves but were excluded from the analysis because they are exceptional cases of charitable action.

We found that 247 of these charities were registered in their own right (labelled ‘individual associated charities’ in Figure 3). The remainder were what is known as ‘linked’ charities, that is, entities associated with larger charitable organisations serving a NHS trust comprising several institutions. These ‘linked’ charities were excluded because it was not possible to disaggregate the support they provide to individual components of the trust. Financial information was available for the period from 1995 to 2014 (only small numbers of observations were available for years prior to that because digitisation of the register began only in the early 1990s).

Measurements

Financial information for at least 1 year between 1995 and 2014 was available for 245 charities in England, and this information formed the final sample for this part of the study. The number of non-zero financial reports to the Commission in each year ranged from 181 (1996) to 226 (2007). The data, covering the period to 2014, were the latest available at the time of analysis (2016). See Appendix 9 for full details of available charity reports by year. All financial information in this paper is presented at constant 2014 prices.

Using the Charity Commission website, we obtained copies of these accounts for those selected charities whose expenditure or income exceeded £25,000 in any one year. This gave data covering 358 separate financial years; the number of accounts available is shown in Table 5.

We focused on the period from 2008 to 2013, when between 41 and 91 charities of interest generated at least one such financial return. Numbers vary because an individual charity may or may not exceed the £25,000 threshold at which its accounts are presented via the Charity Commission’s website, depending on fluctuations in its finances.

Charity accounts aggregate income and expenditure figures into a small number of general categories. These provide relatively little detail on income and expenditure and may even aggregate quite different sources of expenditure within the same funding stream. As such, to probe income sources and the application of expenditure in more detail, data were captured from the notes to the accounts of these charities. The extensive income data that were generated (21,733 items) were categorised to provide useful insights into sources of income. Classifying the expenditure of charities was not undertaken because of the complexity of the data and the limits to the usefulness of such an exercise. Appendix 9 provides further details of the extraction, classification and analysis of income and expenditure data.

Contribution: number of volunteers and estimates of input

The Charity Commission guidelines90 require charities to record their best estimates of the number of individual UK volunteers involved in the charity during the financial year, excluding trustees (see Appendix 9).

Before 2013, data on volunteer numbers were often sparse, but, since that date, efforts have been made to gather more detailed information. Approximately 73,000 charities had supplied between one and three non-zero returns of their volunteer counts in the three years between 2013 and 2015, including > 90% of our charities. We calculated the average number of volunteers for the period in question. To provide an upper-bound estimate, we also take the maximum value returned for each charity.

Volunteer hours were estimated using regular survey data (Home Office Citizenship Survey, 2001–10; Community Life survey, 2012 onwards). We take the average number of hours per week reported by those who say they have given unpaid help to organisations during the previous year. This is approximately 2.2 hours. This is a minimum estimate and it may be that the actual numbers are larger than these survey data would imply. If we make the assumption that these are probably fairly regular volunteers, a higher figure of 3.05 hours per week is given if we take the average number of hours reported by those who say they volunteer either at least once a week or more frequently, or at least monthly but less frequently than once a week.

There are no studies that would tell us with any certainty whether or not volunteers in these kinds of organisations put in more or fewer hours than the volunteering population generally. We then multiply these two estimates of time inputs by the average and maximum volunteer numbers, respectively, to give the number of hours contributed by volunteers over the course of the year (assuming 46 weeks of volunteering a year). These can be converted to full-time equivalent numbers by dividing by 37.5 (hours per working week) and 46 (weeks per working year).

Opinions differ on the best method for calculating a cash equivalent for the value of volunteer labour. The lowest is to use the national minimum wage; others might include an estimate of the replacement cost (i.e. what it would cost the organisation to employ people to do the same tasks if they had to pay them), but this assumes knowledge of the tasks being undertaken. The national minimum wage for the period for which we have the most comprehensive volunteering data (2013–15) was £6.50 per hour. 91

Data convergence and integration

Although the quantitative (phases 1 and 3) and qualitative (phase 2) data were collected separately, they could nevertheless be considered ‘integrated’ because the different research elements were explicitly related to each other within a single study and in such a way ‘as to be mutually illuminating, thereby producing findings that are greater than the sum of the parts’. 92 Data triangulation, convergence and integration occurred in a number of different ways, at different stages of the research.

In phase 1 of the research, a revised definition and set of characteristics captured within the database was used to support development of a typology and informed the case study sampling for phase 2. For phase 3, the database informed the sample of charities selected for analysing voluntary income and volunteering data and providing additional data fields to be linked to the Charity Commission data.

Although the national quantitative data provided breadth to the study, these were limited and left questions unanswered. The local qualitative data brought depth to the question ‘what is a community hospital’, by helping to build a picture of the history, context and change over time. Qualitative interviews in work packages 2 and 3 were conducted concurrently, and triangulation of data between stakeholder, volunteer, staff, carer and patient interviews helped validate findings and strengthen our understanding of patient and carer experiences and community engagement and value.

In addition, the combination of researchers working on more than one work package, reflexive team meetings and the involvement of different representations in the team [CHA, University of Birmingham and Crystal Blue Consulting (London, UK)] allowed for healthy dialogue, debate and analysis. Emerging findings from each phase of the research were, for example, shared through internal working papers and discussed regularly at whole project team meetings.

Broadening the inclusion criteria for group B

Findings from the rapid enquiry supported the conclusion that:

1. community hospitals had no medical presence overnight, and that the matron or ward manager (sister) was the most senior clinical presence 24/7

2. referrals could come from the community but, in practice, mainly came from the acute hospital (i.e. step down)

3. admissions practices indicated a loosening of the ‘local’ role of community hospitals where patients were discharged from acute wards to the next available bed across a group of community hospitals.

The distinction between GP specialty code and consultant geriatrician/physician code was not arbitrary and seemed to indicate a level of formal clinical responsibility for the patient. However, the coding said little about the patient. The case mix and function of community hospitals appeared to be the same for patients whether they were coded to GP or to consultant physicians/geriatrics. The patient mix was reported to be increasingly frail older people with complex needs.

In summary, these findings supported the use of specialty codes as a means of categorising hospitals within national data sets (when combined with size), but needed to be broadened out from GP specialism to include secondary care physician utilisation.

Triangulation

We acknowledge the limitation of overinterpreting output from a small sample within a narrow timescale. Case study data enabled triangulation (see Chapter 4).

In addition, findings from the NHS Benchmarking 2014/1594 data set were consistent with our rapid enquiry:

• clinical leadership – 40% (63 out of 158) sites described themselves as nurse led

• source of referral – 64% of admissions were recorded as coming from the acute hospital, more than twice as many as from the patient’s home (Table 7).

Rurality

In England, 85% of the land is rural but 82% of the population live in urban areas (settlements of > 10,000 people), with 18% in rural areas [i.e. in smaller towns (< 10,000 people), villages, hamlets or isolated dwellings]. 95 Three-fifths (62%) of the set of 267 community hospitals serve a rural population (categories 1 and 2 in Table 11), with a further 16% in ‘urban areas with significant rural’, leaving 22% of sites in fully urban areas. Figure 6 shows a high concentration in the rural South-West Peninsula and the south-east and clusters in, for example, the Cotswolds, Peak District and parts of East Anglia. Figure 7 depicts the geographical spread, based on Strategic Health Authority boundaries that were extant in 2012/13.

FIGURE 6.

Location of the 267 community hospitals in England (2012/13). Source: My Maps data © 2015 Google.

My Maps data © 2015 Google

FIGURE 7.

Rurality93 and location of the 267 community hospitals in England.

Revised definition: ‘typically serving a rural population.’

Deprivation

Community hospitals serve populations that are relatively privileged according to the Index of Multiple Deprivation (IMD). 96 In England, scores range from 0.5 to 92.1 between the most and least deprived neighbourhoods (at lower-layer super output area level). The range is narrower because of offsetting high/low variations when aggregated to CCG level (i.e. from 5.6 to 47.8) (Table 12). Among the 91 CCGs that have a community hospital, the average IMD score is 16.62, which is significantly lower than the average of 25.11 among 117 CCGs with no community hospital (p < 0.00000, analysis of variance).

At the middle super output area level, representing the local community hospital demographics, Figure 8 shows that 30% of community hospitals are located in areas scoring an IMD of ≤ 10, whereas only 6% of hospitals are in the most deprived areas scoring ≥ 40. The deprivation scores are consistent with the rural–urban spread of community hospitals described above.

FIGURE 8.

The IMD scores (MSOA) for 267 community hospitals. MSOA, middle super output area.

Localness

The working definition characteristic of hospitals ‘serving local populations of less than 100,000’ has been considered in the light of (1) available population data and (2) insights gained through the rapid qualitative enquiry.

Mapping community hospitals to 91 CCGs shows that concentration varies between 20 community hospitals in a CCG (equating to 30,000 population per hospital) and 40 CCGs that contain a single community hospital (Figure 9). As it happens, 267 hospitals in 91 CCGs cover a population of 26 million, averaging a population of 100,000 per hospital. But, overall, the data do not tell us very much.

FIGURE 9.

Concentration of 267 community hospitals across 91 CCGs.

Evidence from the rapid qualitative exercise suggested that the concept of localness was being eroded when community hospitals received inpatients on a county-wide basis and GPs stepped back as the patients were no longer ‘theirs’.

Revised definition: reference to population size and localness has been omitted.

Small, usually ≤ 30 beds

Smallness was confirmed as one of the defining features of community hospitals, and was a significant factor in shaping patient experience (see Chapter 5). The bedded capacity of the case studies ranged from 9 to 32, although this fluctuated depending on commissioning decisions and availability of staff. At least two of the case study hospitals had recently closed a number of their beds because of a lack of qualified nursing staff.

Furthermore, the future of community hospital beds was the subject of intense debate locally: ‘beds are absolutely a touchstone issue for the public’ (CHs 8&9, T02). Many respondents argued passionately that community hospital beds continue to provide an important role in acute admission avoidance, step-down rehabilitation and end-of-life care. Some respondents (most often commissioners and senior managers), however, questioned the need for and/or affordability of community hospital beds, suggesting that patients could be better cared for either in their own home or (less often) in acute hospitals. Many, from both sides of the argument, questioned how a ‘new model’ of care at home would be supported considering the significant reductions to social care budgets and problems associated with delivering care across dispersed rural communities.

Typically serving a rural population

The case studies reinforced the significance of ‘rurality’ as a defining feature of community hospitals, although not all community hospitals are in rural locations: one of our case studies was in a city (although situated within a largely rural area). Regardless of their official classification (three of the case studies were classified as semirural, and six were identified as rural), all but the city-based community hospital were described by respondents as being ‘rural’ and (relatively) ‘isolated’ or ‘peripheral’, because they were far from any major centre of population, on the border of two or more counties, or on the coast. Rurality was associated with poor transport links, particularly public transport, which meant that accessing centralised services could be difficult:

Rurality is quite a burden actually. A lot of our patients aren’t as rich as city dwellers and transport is a huge issue really.

CH1, S03

Rurality and isolation were, however, acknowledged to be relative concepts. For two communities, each based 20 miles from their nearest acute hospital, this might represent 30 minutes of travel time for one, and 1 hour of travel time for the other; for an older person reliant on public transport this might represent a significant, challenging journey, whereas for a younger person with access to a car it might not seem far at all. Alongside accessing acute services, respondents identified poor rural transport as exacerbating the challenges of organising care packages to enable patient discharge.

The rural locations of community hospitals were also perceived to exacerbate recruitment challenges, because of poor accessibility and (generally) high housing costs. Recruitment challenges extended from qualified nursing staff to other professions: the inability to recruit a radiologist in one hospital, for example, had resulted in the X-ray facility being closed for several months. In a couple of cases, a number of recruitment issues had, at certain times, coincided to create a particularly challenging, risky, environment. Additional features of rural communities, including a limited and declining range of services, limited employment opportunities and relatively high levels of social capital and volunteering, influenced the function, use and value of community hospitals (see Chapters 5–7).

The one city-based community hospital case study appeared distinct from the others in a number of ways, most notably its lack of active community engagement (see Chapter 6), but also in some aspects of patient experience. As the only city-based hospital within the sample, however, it was not possible to conclude on the significance of this over other influential factors. It had also, for example, changed its function and service mix considerably over time from a workhouse to a DGH to a community hospital. Indeed, some respondents questioned whether or not this case study should be considered a ‘community hospital’ (see Chapter 7).

Without 24/7 medical cover

The mapping work established that community hospitals are distinguished from other hospitals by not having 24/7 medical cover, and this was reflected in the case studies. However, the case studies highlighted variability in the level of cover provided. Although there was clear guidance on the ratio of nursing staff to patients, this was not the case for GPs/doctors and there was considerable variation in the number of hours of medical cover provided. In one case study, the local GP surgery was reportedly contracted to provide just 0.5 hours a day (although in practice it provided more), whereas others had the equivalent of more than one full-time doctor. The difference could not be accounted for by bed numbers alone. Getting the level and type of medical cover ‘right’ was a challenge identified by a number of respondents: too little medical cover could leave patients at risk and contributed to GPs’ reluctance to continue providing cover.

General practitioner or nurse led

The involvement of GPs has historically been a defining feature of community hospitals. The mapping indicated a shift in GP leadership, the extent and significance of which was highlighted in the case studies. Although GPs have traditionally provided medical cover for community hospitals, we identified two distinct medical models:

• general practitioner – in which either one specific GP from a local practice or a number of GPs from one or more practices were responsible for providing medical cover through a service level agreement for a specified number of hours per week

• in-house doctor(s) – salaried doctor(s) employed directly by the trust to work specifically within the hospital.

Overall, there appears to have been a shift away from the first model towards the second. The withdrawal of GPs in a number of community hospitals has been influenced by a number of factors including the increasing acuity of community hospital patients, referrals being drawn from an increasingly wide geographical area and frustrations from GPs who have had admission rights withdrawn and/or find it increasingly difficult to step up their own patients into community hospital beds because of pressures from the acute hospital for step-down beds. The burden on those GPs who remain involved can be considerable:

It was just like looking after our patients but now we don’t know them so it’s changed [. . .] I mean, certainly we have found with our new young GP he could not cope with it, trying to do rounds here at 10 p.m.. It’s not good for the patients either but it’s not good for him and the worry is that if it does not change, you know, as we sort of retire, are they actually going to be able to stick with it?

CH7, S08

Despite these challenges, it was felt that the majority of the GPs interviewed were committed to their local community hospitals and recognised their value in the (rural) health-care system. Regardless of GP involvement and the medical model in operation, in practice, patient care at each of the hospitals was best described as nurse led, with nurses being the constant presence and medical staff providing a service on a sessional basis.

Main inpatient function is to provide step-up and step-down care

The case studies reflected the findings of the national mapping: that community hospitals provide a mix of step-up and step-down care. However, there was a strong suggestion that they are increasingly likely to be operating as step-down facilities (as extensions of acute hospitals), reducing the capacity to provide step-up care.

Increasing pressure from acute hospitals to discharge patients to community hospital beds was seen to have contributed to this general shift in the ratio of step-up to step-down patients. In turn, step-down patients were seen to be contributing to high occupancy rates, an increasing acuity of patients and longer lengths of stay. Together this meant that it was hard to ringfence beds for step-up patients, leaving GPs and residents frustrated when beds were not available for direct admissions, which could in turn contribute to more people going directly to A&E/acute hospitals:

But I think if we looked at figures for the last 6 months, we’d find that the step ups are very reduced, and that’s due to our pressure in the acute, which feeds down to us. They have been on level 4 all summer, which is a high level of crisis [. . .] So that means that they over-ride our ability to be able to keep [. . .] step-up beds because they are just filled [. . .] and we have also been running on almost 100% occupancy constantly for the last 6 months, so, literally, the beds are not cooling before another patient arrives.

CH9, S10

Increased pressure to step down patients also meant that patients were increasingly likely to come from outside the local area. Although this was mentioned in all but one of the case study sites, it was particularly extreme in two cases where a minority of the inpatients at the time of our visits were ‘local’.

The balance of step up and step down was seen as a ‘real battle of philosophies’, raising fundamental questions about the function of community hospitals and whether or not this was shifting from rehabilitation towards subacute care:

It is rehabilitation in one aspect, but it is also semiacute care, hospital care, that we are providing and that is a significant change that we have seen. People before just came for rehab[ilitaion], but now people are coming because they are unwell and we are looking after them and getting them better.

CH9, S01

Many respondents expressed a desire for a higher number of step-up referrals and for community hospitals to play a greater role in acute admission avoidance and broader prevention work.

For frail older patients

Community hospital inpatients were typically described as being ‘very elderly, very frail, multiple comorbidities . . .’, increasingly including patients with dementia, and often with a range of other associated health and social care issues. The ability to provide generalist, holistic care to address these multiple issues was identified as an important and valued aspect of patient experience (see Chapter 5). However, the increasing age and frailty of patients combined with the shift from step-up to step-down care also meant that community hospitals were caring for patients who are increasingly unwell; the level of acuity on many wards was reported to have risen considerably.

The increasing acuity of patients presented a number of challenges for community hospitals, not least relating to the level of medical cover available and the skills of nursing staff. This could result in patients being bounced back to the acute hospital when it became apparent that they were too poorly to be looked after within a community hospital. Some staff talked about being given misleading or incomplete information about prospective patients that could lead to inappropriate admissions:

So, we’ve had patients come over and within a few hours they are back at the [acute] because again they are just not well or they’ll tell us that they are walking and they can transfer with one, they arrive and they cannot walk.

CH7 S09

Although inpatients in all the case studies were typically older, frail and increasingly acute, the age range of all patients varied across the hospitals, influenced by the range of services that were provided, with the presence of a maternity unit and MIU in particular broadening the age and demographic mix of hospital service users.

With an average length of stay typically < 30 days

Considerable developments have taken place over the past decade or so to reduce the ALOSs of community hospitals to typically < 30 days. However, these efforts were being countered by the increasing acuity of patients.

An even more significant challenge to reducing lengths of stay was the (lack of) availability of care packages to enable timely discharge. Underinvestment in community and social services and a lack of domiciliary care services and nursing homes in rural areas were identified as significant contributory factors. It was suggested that a significant proportion of patients within some community hospitals ‘do not need to be there’ but could not be discharged because ‘there are not enough care packages available’. This led some to suggest that community hospitals had become ‘waiting rooms for social services’.

Likely to include rehabilitation and palliative inpatient care and a range of additional services

The main function of the case study hospitals’ inpatient services is rehabilitation, with each contributing to post-acute discharge and acute admission avoidance. In addition, all play an important role in providing end-of-life care. There were, however, differences as to the emphasis placed on these different roles. The provision of generalist intermediary care was a key feature and value of community hospitals:

Well, for me it bridges the gap between traditional general practice and the large secondary care hospital, and that is increasingly important with our patient demographic and rising age of our patients.

CH1, S06

There was considerable variation, however, in the range of services provided. Despite providing 22 beds, for example, one hospital offered very few other services beyond a few outpatient physiotherapy and antenatal clinics. This is in contrast to four hospitals that were typically described as providing ‘cradle-to-grave’ services in that, alongside the beds, they provided maternity services, a MIU, X-ray, and a wide range of outpatient and community services. Thus, the case studies occupied different positions along the intermediate care spectrum identified through our mapping work (see Chapter 3). Although some were firmly positioned in the middle of the intermediate care spectrum, others had additional services that led them towards a primary/community care orientation, whereas still others tended towards the acute orientation end of the spectrum.

These differences in function, service mix and orientation were influenced by a number of factors, including commissioning context, provider characteristics, local ecology of related health and social care services, size and range of services, medical model, patterns of recruitment, community support and transport infrastructure.

Historically embedded

The case study hospitals were of different ages and had different origins, ranging from six that dated back to the 1800s to one that was built in 1975. All but one were in operation prior to the establishment of the NHS. Two had their origins as workhouses, one was built as a First World War memorial and two more became memorial sites. Three started as cottage hospitals founded and run by members of the local community; the early history of one was strongly tied to the local mining community. Most (if not all) had benefited from significant voluntary contributions from either an individual local benefactor or more widespread local investment to get them started – even the newest was built on a plot of land donated by a local resident. The different historic origins and development trajectories of the hospitals influenced contemporary patient experience (see Chapter 5), engagement (see Chapter 6) and value (see Chapter 7).

Operating with complex models of ownership and provision

Although all hospitals were incorporated into the NHS in the 1940s, the current ownership, commissioning and provision of community hospitals were diverse and complex. At the time of the research, one of the hospitals had been (re)built as a Private Finance Initiative, one was owned and had been rebuilt by a local charity, the others were owned either by NHS Property Services Ltd (London, UK) or by a local provider NHS trust. Regardless of legal ownership, many communities (including patients and staff) perceived the hospitals to be theirs (see Chapters 5 and 7).

The commissioning context was also significant. Different commissioners viewed community hospitals, their value and position in the health-care system differently. For some, community hospitals appeared to be ‘key’ to supporting ‘the wider health community’ with an ‘integral role in our discharge and admission avoidance approach’ (CHs 3&4, T02). For others, they appeared more marginal or unaffordable.

Other aspects of context were also influential: some were in Success Regime areas, one was in a vanguard area, one was entering a period of consultation regarding its future, and all were implicated in developing STPs. This complex local policy landscape, combined with a lack of national community hospital policy, was adding to the variation across community hospitals.

There was also variation in the ‘main providers’ (defined here as those responsible for inpatient services) of community hospital services. The main services in two of the hospitals were provided by a CIC that encompassed both health and social care (the contract was awarded to a private provider shortly after our fieldwork at this site). In the others, main inpatient services were provided by NHS trusts, but each trust differed in terms of its focus and its provision of community, acute, mental health and/or social services. In each of the case study sites, the main provider was just one of a number of statutory, voluntary and private providers within the hospital, although the significance of the main provider varied. In one hospital, we identified over 10 providers.

The increasing number and diversity of providers operating services within a single community hospital site was identified as a significant, if not unique, feature of contemporary community hospitals. It was suggested that the lack of a single organisation or person responsible for overseeing each community hospital as a whole exacerbated challenges of integrated working across a multiprovider site. Without any overall control, multiple providers, it was suggested, could lead to fragmentation:

. . . we would love to feed in and out for staff training into different departments, but we’re a different organisation, so what would have been simple within our organisation becomes complex and you have to get a set of special agreements [. . .] we have different induction, you know, different training, different management responsibility, governance. I mean it just goes on and on really. It’s a very peculiar invisible barrier, which the NHS is full of invisible barriers.

CH2, S10

Providing a base for rewarding, integrated and multidisciplinary work

Despite current concerns about fragmentation of providers, community hospitals were more generally seen as important sites for the increasing integration of health and social care across statutory, voluntary and private providers. This was particularly so for those whose main (inpatient) services were provided by an integrated provider and/or where health and social care services were co-located and/or where a single manager had responsibility for health and social care teams.

Significant challenges to integration were noted however, particularly because of pressures on social care budgets. A number of our respondents reported a recent reduction in the presence of social workers at the hospitals and a more general reduction in the capacity of social care teams to support patients.

Multidisciplinary working was also identified as a distinguishing feature and strength of community hospitals and as contributing to the high levels of staff satisfaction we observed. One respondent suggested that this was facilitated through more equal power dynamics between disciplines:

So it’s very different here from when I used to work in an acute hospital many years ago. The doctors there were very much in charge, very much, ‘right, that person can go home tomorrow’. And you’d be scrabbling around trying to get what they need to go home. Whereas here we are having these discussions, aren’t we, about ‘they are well but, OK, they cannot do this, they cannot do the stairs, they have not got their care in place’. And the doctors understand that here.

CH3, S03, focus group (FG)

There were, however, different dimensions to this, and some exceptions. In most cases, it was suggested that there was a strong MDT working across ward-based nursing and therapy teams. This was facilitated by a range of mechanisms (e.g. case meetings, ward meetings, shared notes), teams being permanently based within the hospital and being jointly managed. There was less consensus on the effectiveness of multidisciplinary working across hospital and community teams and across community and acute hospitals.

Constantly evolving in response to external demands

A number of respondents suggested that, as a result of historic evolution, subsequent diversity and ongoing contemporary change, there was a lack of clarity regarding what community hospitals are and what they do. This lack of clarity, it was suggested, left community hospitals vulnerable to questions regarding their relevance and value. Indeed, the current financial, policy and commissioning context, combined with recent changes within community hospitals, had contributed to considerable debate about their future role and function.

It was suggested that, over time, a lack of strategic planning had meant that community hospitals had evolved in different directions: that many had ‘morphed and changed organically’ and that this had ‘contributed to an identity crisis for the [community] hospitals’. Although this ability to adapt was seen as a strength and a sign of resilience, some argued that for the potential of community hospitals to be realised a more strategic approach was needed:

But, of course, we do need to think more strategically. My concern is that, if you like, [this community] hospital at the moment is in the same position, nobody is thinking strategically about it [. . .] But if [this community] hospital could make up its mind about where it needs to be, I think then it could be very much more successful than it is.

CH2, V03

A ‘strategic vision’ was more evident in two of our case studies: in one case a charity owned the hospital and was working hard to develop and deliver its vision of the community hospital in the centre of a health campus, and in the other case a crisis had brought commissioners, providers and the community together to think creatively about the hospital’s future role in the local population’s health care.

Discussions regarding the future of community hospitals centred on their potential as ‘hubs’ for a wider range of health and social care, public and voluntary sector services: ‘a real heart of health and well-being of the community’. Community hospital ‘hubs’, it was suggested, could play a role not only in step-up or step-down care but also in prevention.

Although there was a consensus and enthusiasm regarding the potential for community hospitals to develop as hubs, there was less agreement regarding the provision of beds within them (as discussed above). Although patients, carers and communities generally agreed that inpatient beds should remain a feature of community hospitals with an expanded range of services, commissioners and senior trust staff were more likely to question this. They tended to see ‘hubs’ without beds replacing community hospitals with beds. Any mention of removing beds was strongly opposed by local community members, with a belief that only financial imperatives were driving such decisions, regardless of patient experience and community value:

The line behind all this is the philosophy that the whole driving force is money and the patient is very much far down the list. It is all about money, and not about the patient.

CH5, V03, FG

In some areas, a counter-argument put forward was that communities were not fully informed about either the safety of community hospital beds or the wider context within which they operate:

So I think those people that speak very strongly about community hospitals, the League of Friends and things have got, they might not necessarily see the bigger picture so yeah they will fight very strongly for their community hospital and may not also understand where it fits in into the bigger jigsaw and actually may not be aware of some of its limitations.

CH9, S05

The ability of all stakeholders to influence strategic decisions regarding the future of community hospitals was questioned by community stakeholders in many of the case studies (see Chapter 6).

It is just different

It is unique [. . .] you go out into the day room and you look across those fields, you know, it’s bright and airy and there’s no sort of closed corners or anything. It doesn’t feel like a hospital, does it.

CH6, S05

‘It’s different’ was a frequent response when patients and carers (and indeed staff) were asked to reflect on their experiences of the community hospital, with participants often distinguishing the atmosphere and environment in community hospitals particularly when compared with that in acute care. A difference in ‘pace’ was frequently cited, with a more relaxed environment, less pressure on staff, more time to pay attention to individuals/the whole person (see below) and a strong sense of feeling less anonymous:

The whole thing was so much nicer and easier rather than if she’d have gone into the [acute hospital]. She’d have just been one more elderly person in a great big ward.

CH1, P06

Carers also frequently mentioned differences in the environment and atmosphere, describing community hospitals as cleaner, tidier, more peaceful, quieter and calmer than acute hospital wards: they were more like home than hospital.

Other differences were the outlook and access to gardens, which staff and/or volunteers often facilitated; this made a real difference and lifted patients’ spirits:

I don’t have any children, my dog is my world, and it was possible when I asked the nurses that my parents brought my little dog to the garden outside so that I would be able to see her, which I wouldn’t have got at another hospital.

CH9, P03

Some people talked about the physical size of most community hospitals as being different, particularly in contrast to acute hospitals. Community hospitals were less intimidating, and this, it was suggested, was particularly valued by patients who were older, frail, and confused, or when they were dying:

She was by far and away happier with those visits to [this community hospital] and I think that’s all about the fact that it’s a small community and much less daunting, particularly people who get, and often the case, get a bit confused towards the end of their lives.

CH1, CY04 FG

Others talked about how a ‘community-based’ hospital felt different because of its location and because of a greater chance of being known by staff (we return to this theme in It is known to me):

Because it’s a small community and it’s quite an old-fashioned community here, everybody knows everybody, it’s one of those sorts of places, people know the staff and most of them are very local.

CH8, CA01

In MIUs and clinics, differences related to the design of reception areas and meeting familiar faces, as well as to the environment, waiting times and staff attention:

I think the longest wait I’ve had [. . .] I probably waited best part of an hour but you know, pleasant surroundings, water to drink, loos to go to if necessary, plenty of magazines around and the attention when I get it is faultless, as far as I’m concerned.

CH1, P01

As many people attended clinics on a regular basis, however, ‘familiarity’ sometimes made it difficult for staff to get on with their work:

They stay there talking and it’s like ‘I really need to see the other patient behind you’.

CH1, S04

They recognised, however, that this was a distinguishing feature of working in a community hospital:

You probably know them far more than what you would do if you worked in an acute hospital.

CH1, S04

However, not all patients thought that community hospitals were all that different from acute hospitals in all respects, and not all found all aspects of the environment positive. Issues such as night-time noise from doors or a sluice disturbed some people’s sleep. Some also felt isolated in single rooms and missed the social interaction of multibedded bays, whereas others commented on clinics not being as friendly. Some staff suggested that younger people sometimes associated the hospital atmosphere with an ‘old people’s home’ and felt alienated because of their age.

Like home from home

Many patients and carers directly used the term ‘home’ or ‘homely’ to describe their community hospital, with familiarity, relationships and proximity to their own home contributing to them feeling ‘at’ home. The notion of home also emerged when community hospitals were compared with acute hospitals, with the smallness of the hospital making it feel very much like a ‘family home’. Some Leagues of Friends deliberately invested in more homely design and furnishings, contributing to the creation of a less clinical environment:

I think they felt it was like home. And I think when we designed the hospital and furnished the hospital, we particularly wanted to make it slightly less clinical, you know, so a home from home type of place, you know, that people did feel comfortable in.

CH3, CY02

Staff and community stakeholders recalled with amusement how two community hospitals were locally referred to as the ‘Hilton.’ They associated this with the quality of the food, how patients felt cared for, and the comfortable facilities, such as single rooms and en-suite bathrooms being a ‘luxury’, as well as the way staff responded to calls:

If you needed someone . . . you rang a bell and the response was always immediate, absolutely immediate.

CH1, P03

However, feeling too much at home could have its downsides. Some staff thought that patients expected to be looked after and could end up a little too comfortable, citing times when inpatients did not want to go home:

And then you get some of them, you say they’ve got to go home, they have a little fall so they do not have to go home! They do not fall enough to hurt themselves, but just enough to give them a shock so they will not send them home that day.

CH6, S03

This was mirrored by some patients talking about how they could ‘live here quite happily’ (CH7, P07). However, staff understood that people’s reluctance might be an expression of their fear of social isolation and the lack of similar comforts and levels of support at home:

And then they don’t relish the thought necessarily of going home where they might be isolated or maybe not have all the same services in place or not get that same level of comfort [. . .] and then when it comes closer to that discharge, all of a sudden it’s, ‘Oh, I’m going to be on my own’.

CH7, S04

It is convenient

Being local and accessible (physically closer to home) was also key to patient and carer experiences. Patients and carers valued having a local hospital that they felt was much more convenient than other forms of service delivery, with less distance to travel, ease of parking and less waiting:

It saves us all going in there [acute] and using our money and fuel to get there and parking there and waiting there.

CH1, P06

Convenience was important for both inpatients (and their carers) and outpatients, particularly those who had to attend the hospital regularly for relatively small procedures:

I think convenience does come a lot into it . . . with the ageing population, and having to travel so far, to say it will take 2 minutes to get somewhere for a blood test or it’s going to take you half a day, to go in and, all that sort of thing.

CH2, S10

Being so conveniently located often enabled family members to visit daily, several times a day for some, which was particularly valued. Flexible visiting hours were also seen as convenient and helped both working visitors and older visitors who found driving stressful:

Here, they’re convenient hours because they are 3 till 5, which is better. To me those are better hours [. . .] I can’t travel at night because the lights [. . .] especially through these lanes, they affect me [. . .] It’s hard to judge. It’s a strain. And that affects a lot of people.

CH8, CA02

Weekend services and later opening times for urgent care also provided convenience for the whole family, and a range of local clinics provided easy access:

You can self-refer here for physio[therapist] treatment where normally you would have to go to your doctor, then you have to wait for appointments [. . .] it’s very, very good in the fact that it is almost like a drop-in centre for that.

CH8, CA03

At times, the idea of the convenience of local services appeared to mean more than practicality, encompassing other important social and emotional aspects, such as enabling someone to maintain their independence and dignity through being self-reliant in terms of getting to and from the hospital:

That was that much more convenient and in fact I can drive myself here [. . .] to do it here again makes a big difference in the life of somebody of my age [89 years] and ability to get around and that sort of thing.

CH1, P01

However, the location of a community hospital was not always convenient for everyone. Some of our case studies were located just outside a village or town, making them seem slightly isolated. Moreover, some inpatients who had been referred in to the community hospital from outside the local area talked about feeling a long way from home, even when care was experienced as good. Poor public transport made it difficult for those living outside the immediate area to get to community hospitals when they could not drive:

If you don’t drive, I am afraid the bus, public transport, is appalling. We had one woman whose husband was in here, and sadly she passed away not long ago, but he was in here for quite some time. She would visit every day, she came on the bus. And it took her 1 hour from [town], each way, and of course if you miss one bus, you are in dire straits.

CH5, V01

As an increasing proportion of inpatients within community hospitals are stepped down from acute services (rather than stepped up from the community) and come from outside the local, immediate area, this is likely to become an increasing concern for community hospital patients. This meant that some people had to take taxis, a considerable cost for those living on pensions, or rely on family members to transport them; at times, this meant carers and other family members making big sacrifices:

Yes, well I’ve had to rely on my daughter [to take me to visit my husband in hospital] because I don’t drive and she actually gave up her job because she was going to have like a few months off knowing probably this would be more care.

CH1, CA03

For some, their frustration with the lack of public transport in rural areas was closely linked to their experience of having to drive long journeys to acute hospitals for some clinics, which heightened their concern that community hospitals remain part of local service provision:

It’s a 60-mile round trip for me [to acute], and at 80 years old you do not want to be [. . .] in the winter, driving 60 miles. So when they said she was coming [to the local hospital] I thought, ‘Fine.’ And I thought then, well this is what it should be all about. They should not be trying to put patients away from their families, you should try and consolidate them.

CH2, CA01

It is less stressful and more reassuring

For a number of people, going into hospital itself was experienced as stressful, perhaps because of the anxiety about their illness. Being able to attend a small, local hospital where they were known appeared to relieve this stress: ‘you do not get tensed up about coming here.’ Some patients experienced such a ‘fear’ of hospitals in general that the only way they would be persuaded to accept treatment was by going into a local community hospital:

[This] lady, absolutely epitomises why we need to be here. This is a lady with white coat syndrome, terrified of acute admission, terrified of attending appointments.

CH7, S05 FG

For some ‘fear’ seemed to be linked to separation from what was known and familiar: ‘because they are torn away from everything and everyone.’ For others, anxiety was about hospital size, impersonal surroundings and not knowing anyone there. Being ‘closer to home’, in all the different ways described above (i.e. not just physically), helped to ease these kinds of fears and anxieties for patients attending community hospitals.

Stress and worry were quite often talked about by family members, with the term ‘lifesaver’ used to convey the relief families felt by being able to access local services and receive good care for their loved ones:

It totally saved my life. Without [community hospital] I really don’t know what we’d have done because I was in a total mess with [name] care and, as I’ve said before, I just did not know what to do.

CH3, CA01

For carers, it was reassuring to know that their relatives were being cared for well and nearby, particularly when they were unable to do it themselves and when they were at the end of their tether. When patients were admitted to hospital, carers were concerned about ensuring that their needs were understood and taken care of properly, particularly when relatives could not communicate for themselves. In this context, finding a community hospital where a relative could receive good care provided palpable reassurance for one carer and perhaps shared her burden for a short while, as she had never had more than 1 hour off from caring for her husband:

I just knew that he was safe and for me that was huge. I was trying to work, I was trying to sort out what I was going to do with him, I was trying to sort out my father’s palliative care [. . .] They just seemed to understand here that that’s what we needed . . . I am on my own, I don’t have a support network apart from through the NHS and I haven’t got a clue what I’d have done. I think I would have probably ended up taking him off the bridge or something because there was not anywhere to go. I even went away for a weekend while he was here and left them to it; I had not been away for more than an hour.

CH3, CA01

It is known to me

Local community hospitals often engendered a deep sense of ownership and connectedness, because they were embedded in community history, civic pride, family values and personal significance: ‘I was born on this land here where the hospital is now sited [. . .] and I’ve lived here ever since’ (CH1, P02) (see Chapter 7). This ‘known-ness’ was fundamental to many people’s experiences of community hospital inpatient care, because it was experienced as less anonymous, more understood, more personalised and connected. A staff member, who also used the community hospital as a patient – as did her family – illustrated this fundamental ‘known-ness’:

I suppose for me it’s where I come to work but it’s also my community hospital. This is where I come to use maternity services, we have used outpatient physio[therapy], we have seen consultants here. Used it for lots of reasons so it’s my hospital to come to as well as my place of work. So yeah, it feels like another home and it’s like a good place to come to.

CH3, S03 FG

Knowing others in the local community was a factor that shaped people’s experience of hospital, and this offered a safety blanket at times: ‘my taxi driver always took me indoors [after hospital visits] and checked that there was no sign of break-ins’ (CH2, P07). This safety blanket included staff using personal connections to reassure relatives unable to visit locally: ‘she will report back to a relative [. . .] whose mother is in here’ (CH7, P05). It also included helping ease the anxiety of patients going into an acute hospital that was not local, by community hospital staff asking staff they knew working at the acute hospital to look out for a patient and facilitate a more personal connection:

There is a sister there [in acute] that’s a very good friend of mine [. . .] I will ring her and say, ‘Just say [to the patient] you know [me] very well.’ [. . .] that makes their hospital stay a lot easier knowing that the people who are working there know us.

CH2, CY03

Knowing the community hospital and its staff was often associated with ‘family’ and, in part, this was because of to local families using the community hospital over generations:

That’s because they know us and the wider community now, as their families all know what [the hospital] does and that makes it quite settling for them.

CH3, S01

When patients were not placed in a familiar local hospital, the emotional impact of being away from family and home could be profound. For one patient returning to their local community hospital after a period in an acute hospital, the experience was transformational. His daughter recalled how he had been at the time:

Then dad was transferred to [unfamiliar, acute hospital] and while he was there his mood changed, it was very low mood but as soon as he realised that he would be able to come back to [this community hospital] his mood completely lifted and he came back [. . .] a completely different person [. . .] because he’s a local person and the staff are local and I would add that into the equation, you know [. . .] they recognise dad and dad’s been able to talk to them but dad’s also been able to have his family around more often.

CH3, V03 FG

Familiarity between staff and patients also had practical benefits for patients regularly using the hospital, as both could refer back to recent treatments and this helped to avoid patients having to repeat information about themselves – it helped facilitate continuity of care (see below). Knowledge of patients’ histories also seemed vital when staff needed to understand and appropriately assess patients’ needs:

This is a lady terrified of acute admission, terrified of attending appointments, has struggled and struggled and struggled until basically she’s reached the point of inability to cope and had to concede – her circumstances have forced the situation [. . .] And they [acute hospital] would not have known any of that historical, vitally important [information].

CH7, S05 FG

A low staff turnover (in some of the case studies) meant that patients also had more time to get to know staff: ‘they get to know our nurses because we have such a stable workforce’ (CH3, S01). This stability helped when caring for patients with impaired capacity and offered comfort to relatives:

Yeah because with dementia that’s the thing, they need something fairly stable, don’t they?

CH1, CA03

In contrast, when a local inpatient stay was not possible, the lack of familiarity could cause distress for patients and anguish for relatives:

He was absolutely miserable in [the acute hospital], really miserable [. . .] I can only think because it wasn’t [the local community hospital], because we have been here over the years for minor things with the kids, you know [. . .] we have been here since 1958, but we know everybody and we know all the doctors, you see, that’s what’s so lovely really.

CH5, CA02

Patients visiting outpatient clinics became well known to clinic staff and this regular contact facilitated social connections: ‘They are almost part of the family . . . you do get to know them and that’s really nice’ (CH1, S04). Again, descriptors relating to home and family were prevalent in patients’ and carers’ narratives. Patients knowing each other also presented an opportunity that staff deliberately exploited for patients’ benefit: ‘you know, those two ladies are really sociable let’s get those two in a room together’ (CH1, S01). One man who attended a clinic twice weekly fondly described his experience:

Well, they’re just all so nice, you know [. . .] they are like friends, really, you know. I’ve known them, as I say, for 4 years now, and, you know, they’ll chat and tell you all about their families, what they are up to, holidays and all that sort of thing, and it’s like a sort of social event, really, coming in [laughs].

CH1, P01

For most people, being known was a positive factor. However, for patients and staff, this occasionally presented personal and professional challenges. For patients, being known could mean that ‘everyone knows everyone else’s business’ (CH1, P06). For nursing and therapy staff, knowing patients personally required professional vigilance at all times:

Well, because it’s a small town as well [. . .] a lot of people who work here could obviously know a lot of the people who’s coming in. But you have to remain obviously very professional about that. And staff do know, you know nothing should be talked about.

CH1, S07 FG

This sense of ‘known-ness’, however, was being challenged. Health system changes (referrals taken from a wider geographical patch) meant that the ‘localness’ of inpatients had decreased. Not being known by the doctor or nurses also meant that patients’ expertise and knowledge of their disease was difficult to exercise and was frustrating:

They are given the charts by the doctor and it tells them what insulin, when they can give it, how much to give and, of course, the doctor that is covering this area isn’t obviously known to Dad, Dad does not know him, so obviously they are just going on the basis that the patient is here and that is the insulin they have to have, blah blah blah. Obviously Dad being quite knowledgeable about his diabetes, it is frustrating for him.

CH6, CA01

Staff personally care about me

For people using inpatient facilities and their families, experiences of community hospital care were greatly influenced by the way staff cared for them. Frequently, patients talked about them as ‘welcoming’, warm and attentive:

That’s from everybody, from the auxiliaries to the nursing staff, to the sisters, they all have such a wonderful manner with them and attentive.

CH8, CA03

One patient shared her experience of being admitted to a community hospital late at night and how staff had welcomed her, anticipating her anxiety and need to be settled in quickly:

They were totally welcoming and you felt that everything was prepared and ready [. . .] they had already realised that I needed something to settle and tea and coffee was offered almost immediately. And within half an hour I felt, ‘Thank god for that’, relaxation, that having built yourself up to think, ‘I’m not sure what’s going to happen.

CH7, P05

Some family members talked about how staff related to patients as if they were their own relative: ‘and it’s almost like they are part of their family, the way they look after them’ (CH9, CA03). Patients noticed staff showing genuine concern. They also talked about how staff made them feel welcome, and they never felt in the way:

You never thought that you were taking their time up or getting in their way. Never felt like you were an inconvenience or anything like that.

CH8, CA01

One patient explained how personalised her day-to-day experience had been, and how staff did not take their knowledge of her needs for granted:

And I had the same thing every morning so (laughing) it wasn’t as if they needed to ask every morning, now would you like your white toast with no butter and just marmalade? Yes, please. Black tea? Yes, please. And they would remember.

CH1, P03

At times, providing care meant that staff would have more intimate interactions with patients, particularly around helping with personal care, which some patients could find embarrassing. However, patients talked about the sensitivity with which nurses conducted themselves and how this enabled them to retain some dignity and privacy:

It was difficult at times for me, especially toilet-wise and that sort of thing. I was embarrassed as I’m sure anybody would be but they have never complained. Never a complaint. They wash you and clean you and make you feel whole again, time after time. Time after time.

CH8, P01

For family carers, the dignity and respect given to their older relatives were enormously important:

The respect and dignity they gave to my grandma was a huge thing for my mum and my aunty [. . .] But I feel the respect that’s shown to patients on the ward is – you cannot compare it to anywhere.

CH9, S04

Paying attention to privacy and dignity was important to staff because that is how they wanted to work:

I sometimes think it’s the simple things, isn’t it? People being treated with respect, not just they are old and ill, you know. The staff showing a bit of kindness and consideration. I think things like that are important. You know, it’s awful if you have been in hospital if you get a snappy nurse, you think, ‘Hmm, I don’t want to be here anyway,’ you know. Doesn’t make it nice, does it?

CH9, S07

Alongside nurses, the friendliness and personal contact from domestic and catering staff was also valued:

They all know all the patients and you can hear them in the kitchen when they’re dishing out the lunches and things. They are really caring about who they are giving it to.

CH3, S04

Being offered a choice around food was also a feature of the personalised care provided, and in community hospitals with their own kitchens, patients particularly valued the food being ‘cooked on site’ and personally served to them: ‘they serve it up in front of you’. They also appreciated being offered daily choice and having their individual needs catered for:

I even asked the other day if we could have a jacket potato if we wanted one. She said if you want one, we’ll do one for you. I think you would not get that in a bigger, not in, like, the [acute]. There’s too many people, isn’t there? But in a place like this, I think you’re an individual in a way.

CH3, P03

Most patients and carers spoke positively about staff and the personalised care they received, and it was fairly rare to hear otherwise. However, there were a few instances mentioned. In one community hospital, an outpatient talked about how, previously, there were more staff who took the time to greet him personally. He felt that this was no longer the case because staff were busy and just seemed to get on with their jobs:

You go there nowadays and you are just a person within a building. The staff just walking by don’t acknowledge patients. They don’t say, ‘Are you OK there? Are you in the right place?’ Or just, ‘Good morning, lovely day.’ None of that [. . .] The older hospital, I think, was more personalised because people recognised you from going there.

CH3, P01

They do whatever wants doing

Well, I think it’s the quality and the tenderness of the nursing care, it’s having a medical expertise on tap and an independent assessment will be made of their needs in social services support to get their care package in, home visits if necessary. The sort of link between the hospital environment and the home environment, the discharge planning is a big part of it.

CH5, S14

The ethos of community hospitals seemed to be about, as one patient put it, ‘whatever wants doing’. Indeed, providing holistic care was seen as a distinguishing feature when compared with acute hospital care: ‘[in acute hospitals] it’s really just a snapshot of the person in that situation by the bed. It’s not the whole picture’ (CH2, S14). Specialist expertise, time and a non-clinical approach were all used to put this ethos into practice:

You go to a local community hospital and you see a specialist nurse who’s maybe not in a uniform, and who has time to sit down and have a conversation with you.

CH4, S09

For patients, a major benefit of this ethos and practice was having all their needs assessed and treated, rather than staff dealing only with the presenting problem. Staff carried out comprehensive needs assessments – ‘we look at the whole person’ – which were seen to be particularly relevant for older people with a number of underlying conditions. There were numerous examples of staff identifying and addressing issues that had not been picked up during patients’ admissions to acute care, and this holistic, ‘generalist’ approach (rather than a disease-specific or single-issue approach) was thought to be an important feature of patients’ experiences of community hospital. The thoroughness of this holistic approach was recognised by patients:

They find out all sorts of thing about you when you come in. [laughing] Because they’ve found now that I’ve got trouble with my heart.

CH3, P03

Assessments were multidisciplinary and addressed a number of needs, such a person’s physical health, medication, cognition, mobility, living situation and social support needs. This was done alongside patients’ personal wishes and expectations of themselves. Although some of the case study sites provided some specialist mental health services, we saw little explicit evidence of mental health needs, for example anxiety and depression, being considered as part of the overall needs assessment (beyond cognitive functioning), or of mental health being seen as integral to inpatient care practice. This is discussed in more detail in It is a huge life event: psychological transitions.

However, when undertaking an assessment, staff did recognise the importance of involving family members and worked to build a good relationship with them, arranging meetings at the beginning and over the duration of the stay, to inform and involve them in what was likely to happen:

We involve families from day one, as soon as we meet them we give them ideas of what the procedures are and how long we expect their family to be here, so people have a broad outline of what we’re gonna be doing.

CH3, S01

Ongoing multidisciplinary support together with home visits, and close work with patients and their families, all enabled staff to put together tailored packages of care: ‘we all work together to make sure that the package of care is the correct package of care’ (CH2, S07 and S08). They also focused on supporting a person’s discharge home and enabling them to remain there safely: ‘we make sure the discharge is very safe and we build up a relationship with the patient and their families.’ (CH3, S01).

The first practical step towards going home was planning for discharge, with staff across a number of disciplines focusing on helping people return home:

I work very, very closely with [. . .] the nurses on the ward, the doctors, physiotherapists, occupational therapists, social services to look at what that person is going to need, if anything, when they go home.

CH2, S05

Home visits supported this and were seen as a feature of community hospital care: ‘You’re more likely to do home visits or environmental visits which potentially you would not do within [acute] so much’ (CH1, S07, FG). This provided an important opportunity to glean more information about the person in their home context. One patient talked about her home visit and how staff assessed, supported and encouraged her to understand how well she could cope at home:

Well, the home visit was about 3 or 4 days [. . .] before I was discharged [. . .] I did walk up the steps . . . they measured the height of the loo and looked at the shower and the kitchen and had me walking with the Zimmer [. . .] so they then had me going round the kitchen, furniture walking, they called it. [laughing] They had me getting onto and off the bed with a piece of kit, which you’ve probably come across, called a leg lifter [. . .] a magic piece of kit. It is so simple, but so helpful when you are first doing those sort of movements [. . .] and again, it was a confidence booster [. . .] you’d got someone there to see how you coped with it and offer you advice on how to do it differently, if there was a better way of doing it.

CH1, P03

There were times when patients’ and carers’ expectations of treatment differed from that provided, often in relation to physiotherapy. At times, this was because patients did not recognise the ‘informal’ physiotherapy being undertaken by nurses. One member of staff described how patients can be left disappointed:

Well, patients often are shocked that they’re not having ‘formal’ physio[therapy]. They are led to believe when they are at the [acute] that they are going to come for intensive rehabilitation and they do not recognise this is intensive rehabilitation. And they are bitterly disappointed.

CH4, S06

Staff members also described how expectations may be built up when people are being discharged from acute hospital, and insufficient staffing meant that they were not able to always meet these expectations:

It depends how it’s been sold to them at say the [acute] if they are coming across. They, you know, whoever’s told them they have got to move on [. . .] they might have said, ‘oh, you can go there and have intense physio[therapy]’ [. . .] actually you cannot. There’s not enough staff.

CH3, S03 FG

In addition to insufficient staffing, the inexperience of some nursing staff in working with people with complex needs meant that, at times, multidisciplinary care planning was not followed, and this could concern family members:

I think some of the nurses there maybe don’t have the support, the training, the skills that they need to deal with the more complex service users, and so they get impatient with them or they do not follow the protocol. I’ve certainly had that from family members where they said, ‘The physio[therapist] has said they need to transfer like this or they need to be doing this but the nurses did it all wrong.’ So I think there maybe are some issues.

CH4, S07 FG

They help me to recover and return home

[They] give them the best opportunity they can to return home, if that’s where they want to go, and to stay at home. It’s a stepping stone back to try and get a bit of normality in their lives, really.

CH4, S09

The approach to ‘rehabilitation’ across community hospitals was usually informed by patients’ personal goals as well as what they needed to get around their home as part of their daily living. For staff, this started with focusing on short-term goals:

It’s a little more goal orientated for us [. . .] all they want to do is be able to walk down to the bottom of their garden and get to their greenhouse. So we pick up that individual personal goal that needs to be achieved for them to get home or to get back to their baseline.

CH1, S07 FG

When setting goals, staff talked about the need for realism as well as recognising a person’s potential: ‘Look at the bigger picture all the time [. . .] maybe they can and it’s giving them that opportunity to be able to do that’ (CH1, S05). A major part of their rehabilitation work was also to encourage patients who, for one reason or other, may have stopped doing things for themselves:

As soon as they come into hospital, they just stop, and I think a big part of particularly here – I couldn’t say for other community hospitals but I would imagine it is – is stopping that. Is bringing that back and saying, ‘Actually, you can brush your own teeth . . .’.

CH2, S05

Once agreed, staff worked together with patients and their families to implement a care plan. Treatment and care varied depending on individual need but often involved a brief period of recovery before starting regular physiotherapy to build their confidence around balance and walking, practising daily living with occupational therapy support (e.g. being in a kitchen) and preparing (home visits) for going home. As time spent in hospital could last several weeks, a relationship between visiting relatives and staff often developed over this time.

For carers, being included, involved and informed seemed paramount. One woman recalled how staff had quickly got to know her husband and her, and how they had kept her informed about his health when she visited. She went on to explain how important proactive communication was, particularly when caring for people with dementia, suggesting that staff had a double task in such circumstances:

If you have someone with dementia, you are really dealing with two people, you are dealing with the person with dementia and their carer. You need to care for one and you need to communicate with the other.

CH3, CA01

During inpatient stays, staff worked progressively to improve people’s physical health and strengthen their mobility, recognising the multiple comorbidities that patients had to contend with during recovery:

So they are very elderly, very frail, multiple comorbidities, and it can be everything from a routine hip replacement or planned bowel surgery or something and recovery from that, because they are frail it’s taking longer, to a fall at home, not found for 3 days, people with UTIs [urinary tract infections] or chest infections and they just lose the power of their legs and get very confused. So not only do they have to get over that illness, they have then got to regain their strength and their confidence in order to hopefully get back home.

CH1, S01

The degree of complexity varied, and for some patients their recovery was more straightforward. A woman who spent 3 weeks in her local community hospital recovering from surgery after having badly broken her pelvis illustrates how staff had steadily supported her physical rehabilitation through praise and encouragement:

From the moment I got here they made me feel as though they were here to make me better and they were here to help me progress forward; it’s not, ‘Oh, you’re here. You can just sit and do nothing.’ ‘Oh, you’re here; we want you there’. ‘You can have that but we want to take your commode away; you’re not going to have it there all the time.’ ‘You will hop down there.’ ‘If you’re capable you will go and have your own shower and wash your hair and do all those sorts of things.’ And each day they praise you for achieving something new, I mean stupid little things like I can now stand on one leg and clean my teeth with the basin which for the first bit, because I could not have it hanging there, I could not do [. . .] that was another achievement one day. And I think it doesn’t matter whether it’s me or anybody else, they are looking for you to achieve one little thing, maybe not every day, but every time you achieve something you get the feeling that they are pleased for you, and I think that’s vital and that again is the building of the confidence for people to go home.

CH7, P05

She stressed the importance of building people’s confidence when sharing a story about another patient to highlight just how frightened people can become:

Daphne was absolutely furious, the whole thing was a disaster. By the time she was leaving, she was the most jolly soul. She was here a fortnight and [. . .] every time she walked past there was a joke, she was smiling, she couldn’t wait to go home, she felt confident in herself; and that purely because they’d had time to bring her from being an angry old lady, probably very frightened I should imagine, to being somebody who was confident to go home again.

CH5, P05

Recovering from illness or a fall sufficiently well to return home could take many weeks, with ‘formal’ rehabilitation activities taking up only part of each day. This meant that time, and what to do with it, became a significant feature of daily inpatient life. Patients commented on the lack of social stimulation: ‘[it’s] pretty boring laying [sic.] here all day’. Carers also noticed this, particularly when their relatives were recovering:

When Dad was poorly, when he felt really poorly, it was OK because he was sleeping a lot but as soon as he started to pick up he felt bored . . . I think once you’re getting better there does not seem to be very much [. . .] what’s the word I’m looking for [. . .] yes, [to] keep them stimulated.

CH9, CA05

They also noticed that some of the dedicated facilities lacked atmosphere and appeared underused:

It’s a big room but it’s [. . .] hardly anybody uses it. Another chap next door to my dad had gone through to watch the television because he was aware that other people in his room did not want to, but he said, ‘I didn’t like it in there, I felt completely on my own’. There was nobody else there apart from him, he’d been wheeled through sitting there, in a cold-ish room, just because it was big and just on his own but nobody else there.

CH8, CA03

The lack of ‘things to do’ was observed across a number of case study sites, raising a question as to whether or not more could be done to support social interaction between patients. Staff accounted for the lack of social stimulation in different ways. In one community hospital, they suggested that activities were limited because patients were quite unwell, whereas others indicated that staff shortages might be a reason. However, this varied within and between hospitals and there were also some good examples of social stimulation supported by volunteers as well as examples of excellent staff support. The same carer who spoke about the cold and empty day room also recalled how an occupational therapist had provided some ‘brilliant’ stimulation for her mum:

One of the occupational staff members – she was brilliant with Mum. She would go and sit in. And we even had her singing at one point, my mum, in the hospital. She actually could sing, but she couldn’t speak.

CH8, CA03

At times, the social interactions between patients also provided stimulation and helped people to forget about their health or mobility difficulties:

And it was brilliant because, you know, we’re social animals, and that also is part of your recovery, I think. And I laughed my way out of hospital there, you know, because they were such [. . .] I mean, there were two, a couple of youngish girls there who were not very well actually, but their sense of humour was just amazing, you forgot about yourself, you know.

CH5, CA02

Despite lots of positives, discharge could often be a source of tension between staff, patients and family carers. Sometimes this was because patients did not wish to return home because of the pending social isolation and having to take care of themselves, or because their families needed a break or the patient did not have family support. At other times, pressure from acute hospitals to take people who no longer needed acute care (step down) meant that staff had to juggle priorities and this pressure then could be transferred to family carers, who would find themselves responsible for caring for their relatives before they felt able to cope:

The pressure came because the [acute hospital] was on black so they were under pressure for beds here [. . .] but I knew that if I didn’t stand my ground that we were totally out on a limb. He was in hospital, I knew that he was being cared for, but as soon as I allowed him to be discharged, then I was on my own, so that was really difficult. I sat in meetings with five or six people just saying ‘No’.

CH3, CA01

Delayed discharges were often attributable to cuts in social care and this had a major impact on family members:

I found the social services side of it very hard really and not really kept in the loop. It was almost like they’re really under pressure to find places but there are not places for somebody with as much going on as my father had at the end, if you will. Yes, I found that quite hard and it becomes distressing, especially for my mother.

CH9, CA03

There were also many accounts of patients not being able to return home, either because their home was no longer suitable or because a person needed more care than their partner was able to provide. At times like these, when staff had had done as much as they could and going home was no longer an option, this had to be discussed with patients and their families. The impact of this is discussed in the next section.

Levels of volunteering

Returns to the Charity Commission suggest that, on average, Leagues of Friends involve 24 volunteers: an estimated total of 5880 volunteers across the 245 community hospitals that we identified as having such a group. Depending on assumptions made about the average hours contributed each week (see Chapter 2), this equates to between 1.4 and 2.5 full-time equivalent personnel or a financial input of £15,600–28,500 per hospital, or £3.8–6.9M across England. These figures are likely to be underestimates: they exclude trustees and are unlikely to include those who volunteer outside the League of Friends, and the calculations use national averages for volunteer hours and the minimum national hourly wages (see Chapter 2).

Among the 197 community hospital League of Friends that reported volunteer numbers to the Charity Commission, the range was from 2 to 162 volunteers. Among our case studies, one currently had no League of Friends and only ‘one or two’ volunteers involved directly on the wards; Charity Commission returns for the others gave figures of between 6 and 33 volunteers (although our qualitative findings reinforce the view that these are likely to be underestimates).

Volunteering roles and activities

Volunteers from our case studies undertook a range of roles as summarised in Table 18.

In some of our case studies, volunteering roles were limited to fundraising, with very few volunteer roles within the hospital itself. In others, we found a greater range and mix. There was a clear consensus that volunteers could not get involved in medical or personal care or access confidential data and that they were there to complement paid staff. There was far less consensus on the actual roles that they could undertake.

Regulations regarding health and safety and confidentiality were the most commonly cited restrictions on volunteer involvement, but these seemed to be interpreted differently in different hospitals. In some, they were seen as reasons not to involve volunteers, in others they were seen to represent a set of training requirements or a need for expectation management, but it was emphasised that any risks could easily be managed:

I think the majority of people are absolutely safe and would not bring risk into a community hospital . . . These are intelligent people who’ve retired often, who’ve got intellect and skills that they want to do something.

CH1, S08

The range of roles and activities that volunteers could undertake was perceived to be limited by the capacity of patients to engage with them and the capacity of staff to support or facilitate volunteering. Some staff only ‘wanted them to do things that weren’t generating more work for us’ (CH3, S03, FG). It was also reported that some patients and/or their families raised concerns about the involvement of volunteers in their care, necessitating communication regarding the distinction between staff and volunteers.

It was suggested that these factors combined to limit the breadth of volunteer involvement in community hospitals. These constraints contributed to a perception among a number of respondents that community hospitals were putting ‘barriers up where they don’t exist’ and were not always making the most of (potential) ‘untapped resource’ available to them.

Volunteering co-ordination and support

Much of the volunteering within community hospitals was organised through the League of Friends. In some hospitals, a specific League of Friends committee member had been allocated the role of volunteer co-ordinator, with responsibility for recruiting and supporting volunteers. In others, there was less explicit consideration of the need for volunteer co-ordination.

Members of the community could also volunteer directly with the hospital, with their input co-ordinated by a member of staff or by a voluntary service manager (VSM), or equivalent, working at trust level across a number of sites. In some of our case study hospitals, the trust VSM was a regular presence and significant influence, but in most they appeared remote, both geographically and practically. In one hospital, a close link had been forged with external volunteer support agencies. Increasing involvement of trusts in volunteering at community hospitals was sometimes considered as a more bureaucratic approach through, for example, the introduction of additional paperwork, health checks and training, which was welcomed by some but not by all. In some of the case studies, there was tacit acceptance of the place of the volunteer; in others, volunteering, and wider community engagement, was actively encouraged and ‘nurtured’:

We actively encourage our League of Friends to come in whenever they want. And I attend everything they do as well [. . .] If anyone ever asks to come here, to provide any kind of service, we do actively encourage that and we want people to be involved with us.

CH3, S01

Overall, despite a general acknowledgement of the need to nurture volunteering and the value of doing so, examples of a more considered or strategic approach to volunteer co-ordination and development were limited (see Naylor et al. 42 for similar findings regarding volunteering in acute hospitals).

Patterns of volunteering: diversity, recruitment, retention and commitment

There are no quantitative data available on who volunteers in community hospitals. Our case studies, however, suggest that the majority of volunteers were retired, female, white and middle class. In part, this reflects the characteristics of the communities within which many community hospitals are located. Although not dominated by current or retired hospital (and other health/social care) staff, their involvement was also notable. It was not unusual for League of Friends committee members to be well into their 80s, with a majority aged> 65 years of age. This was identified as a challenge for future sustainability:

. . . look at the average age of people who are running it. I mean, we fear for the future because you know . . . 60 plus is quite young actually . . .

CH3, CY01, FG

In one case study hospital, the League of Friends had ceased to operate as previous volunteers retired and they had been unable to recruit new members to take over. Difficulties in recruiting younger people (particularly to committee roles) was attributed to the busy lives that younger people led, the types of activities they do/do not engage in and also the (lack of) relevance of the community hospital services to them.

Overall, although there were generally high levels of latent support for community hospitals (demonstrated, for example, through membership), it was difficult to convert this into active, and particularly regular, volunteer engagement:

I think that a lot of people would go up in arms if it was closed but whether they’d be willing to do anything about it to help, I don’t know. There seems to be a little core of people who would but I’m not sure that that spreads right out across the community.

CH9, CA05

These challenges were exacerbated by a reliance on recruitment through the personal and social networks of those already involved. There was limited evidence of wider, more active or formal forms of volunteer recruitment and a general acknowledgement that they did not quite know how to reach out and engage a wider range of people.

There were, however, exceptions: in one case study, the League of Friends, and volunteering within the hospital more generally, had been reinvigorated following the recruitment of a new chairperson. A number of the case studies involved some young people as volunteers through student placements, through Girl Guides or school groups, or through tailored fundraising activities. One hospital had employed a fundraiser with responsibility for building community support, and it was suggested that this had allowed them to focus attention on diversifying engagement. Together, such examples suggested that concerted efforts to broaden engagement could pay off.

Once involved, volunteers tended to stay involved for considerable periods of time. It was not uncommon for League of Friends committee members to have been involved for well over 20 years or for volunteering to span generations:

Her mother did the library trolley for 40 years and when the hospital closed that was it, she was in her 80s by then. When it opened again, she said, ‘Well darling, I’ll buy a new trolley and perhaps you’d do it instead now’ and darling did, she’s done it ever since [. . .] and that means going and changing the books once a fortnight.

CH7, V04

Regular volunteers often contributed considerable amounts of time, often ‘doing something’ most days of the week. One volunteer respondent had worked at the hospital 6 days a week, 1.5 hours a day, for over 10 years. For some, it was ‘more like being at work’. This level of commitment contributed to a risk of burn-out and, once involved, some volunteers found it hard to say no:

It was much more than we ever expected it to be and, to be quite honest, if I knew 2 years ago that I would be involved in so much I don’t know if I would have done it, because I probably have an average of five health meetings a week.

CH8, V01

Such intense forms of engagement occasionally also represented a challenge for hospital staff. Some volunteers were reported to have ‘gone beyond the boundaries’ of acceptable behaviour (e.g. walking through wards with apparently little concern for patient privacy) because of an overfamiliarity and sense of entitlement that came through their intensive involvement. This is the terrain of the Lampard Inquiry101 into the implications for hospital governance of allowing prominent fundraisers undue influence.

Beyond this relatively small group of very active volunteers, a wider group provided a regular but more limited input and a wider group still helped out on an occasional basis, particularly to support specific fundraising events.

A much larger group of people provided more passive support: they paid their membership fees, made donations and turned up to events but did not help with the organising. This ‘really strong network of supporters’ was typified by one respondent as providing ‘quiet support and acceptance’ and characterised as an ‘important and valued feature of community hospitals’, although the challenge of converting it into more active engagement was recognised:

Bearing in mind we have a catchment area of 70,000 people, very, very few people turn up [to support League of Friends events]. It’s not part of the culture, if you like.

CH2, V03

Overall, respondents in most of our case studies reported widespread community support for the hospital, although there was a clear pyramid of involvement, from a relatively small number of active and regular volunteers to a much wider group providing more passive support in the form of membership or event attendance. The limitations of our research (see Chapters 2 and 8), however, meant that we did not reach beyond those who had some connection to or interest in the hospital.

Levels of charitable income

Communities also support their hospitals through giving money. In 2014, on average, community hospital Leagues of Friends generated an income of £45,387 (Figure 12). This figure is influenced by a small number of very large outliers. The median is £15,632. In addition, some community hospitals benefit from income generated through donations made to NHS trusts; these additional funds were particularly significant in three of our case studies. As discussed in Chapter 2, however, our quantitative data are confined to income generated through Leagues of Friends.

FIGURE 12.

League of Friends income distribution in 2014. Notes: solid line, mean (£45,387); dashed line, median (£15,632).

Two indicators of the relative significance of this source of funding can be given. First, 40% of the Leagues of Friends in our sample were among the top 100 charities in their local authorities in terms of income; in three local authorities, they were among the top 10. Second, our analysis suggests that Leagues of Friends are likely to be among the largest and most stable charities in many of the communities within which they are based (e.g. around 40% of them made non-zero returns to the Charity Commission in every financial year from 1995 to 2014, compared with a national proportion of approximately 10%). This is important in terms of the wider social contribution made by community hospitals. The stability of the institution, its visibility and presence provide a base for various forms of participation.

Sources of income

Leagues of Friends, and other charities involved in supporting community hospitals, engage in a range of activities to generate their income, including domino nights, car boot sales, fêtes, fashion shows, charity shops, providing day care services and (very rarely) significant property investment portfolios. Table 19 presents an overview of income sources, derived from charity accounts from Leagues of Friends with an income or expenditure of > £25,000 in any given year (reflected in annual variations of the number of observations).

Over a 5-year period (2008–13), three-quarters (77%) of Leagues of Friends’ income was ‘voluntary income’ generated through gifts, donations, legacies, grants, membership subscriptions and sponsorships (see Table 19). More than half of ‘voluntary income’ (indeed, two-fifths of all income) came from legacies. Legacies were more significant for community hospital Leagues of Friends than for other charities. One-sixth (15%) of income was from ‘activities for generating funds’, such as jumble sales, lotteries and charity shops. Less than one-tenth was raised through ‘charitable activities’, such as trading goods and services. In this regard the Leagues of Friends are fairly typical of local charitable organisations. They do not rely on statutory funding or on contracts. These forms of fundraising are an outcome of, and contribute to the formation of social capital through, active fundraising efforts.

Variations in income levels

Although the mean income for League of Friends in 2014 was £45,387, the median was £15,632, suggesting considerable variation. Most (65%, n = 130) Leagues of Friends had an income of < £25,000 a year, around 35% (n = 70) had an income of between £25,000 and £499,000 and only one had an income of > £500,000. We observed occasional years in which income exceeded £1M, generally associated with ad hoc inflows, such as large legacies.

Figure 13 shows how average levels of income vary over time. The trend is now downwards: League of Friends’ incomes have been declining since 1995. The decline was most pronounced in 2011 and 2012, but showed signs of recovery in 2013 and 2014.

FIGURE 13.

Variation in average levels of income over time (League of Friends). 89

To test whether or not temporal changes were statistically significant, we conducted a fixed-effects regression analysis, entering a constant term and year as the only predictors, in order to compare income with that of a base category (income in 1995). The graph suggests that, in general, the average and median income that Leagues of Friends have received yearly was on the rise until the mid-2000s but since then it has declined. Our analysis suggests 2 peak years of income: 2000, when annual income significantly (at p < 0.01) exceeded the income in the base year for comparison (1995), for the first time, by £22,304, and in 2006, when the annual income exceeded the income in 1995 by £15,454 (p < 0.05). The decline in income was statistically significant (p < 0.05) in 2 years: 2011 and 2012. Then, charities received £18,820 and £18,197, respectively, less than in 1995. In other words, these results indicate that 2011 and 2012 were the years when, for the first time, charity income dropped substantially from the income level of 1995. The analysis also indicates that the decline in income in general has been statistically significant (b = –901.29, p < 0.01). This means that, since 1995, the charitable income of Leagues of Friends has declined on average by approximately £901 a year.

Notwithstanding this finding, there was little evidence among our case studies of concern over declining levels of income, although some Leagues of Friends felt that they had relatively low levels of income compared with others nearby: ‘others experiencing the converse of this’ (CH3, V01). The receipt of significant legacies was seen by some to offset the need to fundraise.

Some had limited their fundraising activities, recognising a potential crowding out of other local charities, had continued to run fundraising activities but had shared the proceeds with other related charities or were holding key fundraising events every other year, with another charity running theirs on the alternate years, so that ‘not one [charity] is hogging all of it’.

Although declining income was not identified as a current issue, some did question the future sustainability of income levels. Where inpatients were increasingly drawn from outside the local area and/or where the range of services had declined, this would weaken the local base on which the hospital had relied, reducing the League of Friends’ membership base.

Furthermore, concerns were raised with regard to declining membership levels. This would be reflected in declining income, but was seen more as a concerning indicator of a reduction in engagement with the hospital in general. Declining membership was also linked to the current economic conditions and to questions over the relevance of community hospital services to some community members. Although some of our case studies seemed resigned to declining membership, others had been working to address it.

Expenditure

Expenditure has also declined, but less sharply than income. Since 1995, the Leagues of Friends have, in most years, received more than they have spent, indicating that they have been building reserves. The exceptions from this trend are the years 1997 and 2011, when an average Leagues of Friends group spent more than it received. Overall, within the data set that we have, it appears that in 2011 their funding position was at its weakest since 1995: income was at its lowest and expenditure was relatively high, exceeding income (Figure 14).

FIGURE 14.

Categorising League of Friends expenditure over time. 89

Underneath these national trends in levels of expenditure, the case studies enable a more textured account of expenditure. Table 20 summarises the key categories of expenditure found in the case studies. The nature of the data means that we have not had the scope to quantify this in detail.

The boundaries between what were and were not considered appropriate forms of expenditure varied between hospitals and over time, with a particular concern for where the boundary should be drawn between voluntary and statutory responsibility.

How these were defined did not follow a hard and fast rule, raising wider issues of policy. Some adopted a clear demarcation, avoiding anything that they felt was the preserve of statutory responsibility (e.g. buildings, equipment). But we also found examples of support being extended to other health services connected to the hospital (e.g. district nurses), to individual patients and carers (e.g. to purchase equipment in patients’ homes to enable discharge) and beyond. One League of Friends had changed its constitution, responding to the increasing use of inpatient beds for non-local residents, which the League of Friends felt had resulted in it becoming less relevant to the local community:

. . . we felt that focusing solely on the hospital was no longer a proper use of the funds that came in because people were giving it for something that didn’t really exist any more.

CH6, V01

In general, the boundaries defining appropriate/inappropriate expenditure were becoming greyer as hospitals/NHS trusts faced considerable financial challenges. Covering staff costs was a clear example: one League of Friends was paying for a chaplain (after the trust ‘dispensed’ with the service) and a gardener and had funded the extension of the minor injury unit opening hours. Such decisions often came with reservations:

We are supposed to help the hospital for extras. This was how it started off. It has got to be very much more mainstream now because of lack of funds.

CH9, V01

A more specific concern regarding expenditure arose in a number of case studies in which uncertainty regarding the future of the hospital contributed to hesitancy to invest. One example given involved the restriction of fundraising in response to uncertainty about the hospital’s future:

[W]e talked to the NHS about building a public walkway between the ward and the day centre and we would happily pay for, and they absolutely point blank refused to consider it [. . .] Because it’s their building. Possibly because they might have been in the back of their mind thinking ‘we are going to be closing it anyway’, we don’t know.

CH5, V02

Concerns were also raised regarding the ownership of community hospitals, with a suggestion that some Leagues of Friends were less willing to commit to expenditure relating to refurbishment if the building had come into the ownership of NHS Property Company as opposed to an individual trust. The challenges of allocating resources to a growing number of providers within individual community hospitals were also highlighted:

But now you are dealing with five or six different providers, you are beginning to think, well, where is the benefit of this property, or this equipment? Where even now, every piece of equipment we buy we do get a signature from someone in charge of that department saying that it still continues to belong to the League of Friends, because you find that you brought it and it has gone and been used in another hospital, because of this change.

CH2, V01

More specific still were discussions around the processes for approving and enacting expenditure and the subsequent utilisation and sustainability of any items purchased. Criticisms were made of inappropriate or unsustainable purchases illustrative of broader weaknesses of charitable giving: philanthropic particularism, devoting resources to items that did not really meet community needs. These frustrations were balanced against the overall contribution that such expenditure made to the hospitals.

Communication

An important role for the League of Friends was to provide a communication channel between the hospital and its community. This could take the form of raising the profile of the hospital and providing feedback on services. Members of the League of Friends were well placed to do this:

Every member [of the League of Friends] has neighbours, friends, all the organisations they go to, they go out to lunch, they meet people, and we will then feed anything back to the trust that has gone wrong, particularly now we’ve got a governor because they are able and the trust are actually very, very open with us.

CH9, V01

For some Leagues of Friends, providing a communication channel and profile raising had become explicit aims with a set of specific associated activities, ranging from running social media campaigns through to providing signage and leafleting local residents to encourage correct MIU usage and organising events. Two hospitals, for example, had reintroduced fêtes with the specific aim of helping to raise the profile of the hospital. One was thinking of establishing a network of ambassadors: volunteers living within the surrounding villages who would have a specific remit to raise the profile of the hospital. For others, such outcomes were more of a coincidental outcome of other (fundraising) activities that they were undertaking, although one might argue that, even if unintended, the latent benefits of voluntary action are evident (see below for further discussion on outcomes).

Consultation

A number of the case study sites had active consultations running at the time of the research, with particular implications for the future of community hospital beds. Most had prior experience of such processes. Leagues of Friends had come, by design or default, to represent the ‘voice of the community’ in many such consultation processes. This was not always a role they had anticipated, or had the capacity to fulfil, and some were more comfortable with it than others. One League of Friends chairperson admitted that, although they could act as a conduit of opinions between the community and NHS management:

I did not feel like I was representing the whole of [the] community. It did not feel quite right. And cynically it felt like it was going through a process and whatever we said did not actually make any [. . .] difference in the long run.

CH1, V04

Considerable frustration was expressed about such consultations, focusing on poor processes (e.g. lengthy documents, technical language, onerous schedules), lack of timely communication, uneven engagement (e.g. consultations failed to engage the range of groups within the local population) and an apparent inability to influence outcomes. Often, consultations were dismissed as token exercises, with a perception of decisions having been made prior to opinions being sought.

Trusts and CCGs recognised the importance of consultation, particularly given the attachment that many people had to their local hospital. It was suggested that communities would react more ‘reasonably’ to the changes that CCGs felt needed to be made if they had been involved in the decisions and understood the context behind them. Some commissioners, however, also expressed their own frustrations about the consultation processes, suggesting that:

However much you do, it’s never enough and some people will always feel that they have, in some way, been excluded. I’ve kind of grown tired actually of looking people in the eye and saying, ‘You know what? I’m here to listen. We have not already decided and you can believe us or not on that but I’d like to hear your views’.

CH8&9, T02

Co-production

Moving beyond periodic consultation exercises, examples of sustained patient and/or wider community involvement in the ongoing design and delivery of community hospitals was also limited (with two notable exceptions – see below). Indeed, considerable frustration was expressed by some respondents that they had no guaranteed and ongoing place in governance processes: ‘decisions are made by the hospital without really engaging with the community’ (CH2, CY04, FG).

Strong feelings were expressed particularly in relation to times of threat to the hospital or its services, affecting three of the case studies during the research. Most had experienced threats at least once, often more, in the past: one had ‘fought many battles over the years’ to save the hospital.

There was a discussion in interviews and focus groups about the most appropriate mechanism or body to ensure that the ‘voice of the community’ was heard. Protest, or ‘ginger’, groups had been established in at least two of the case study communities during previous moments of threat; they could, it was suggested, be more overtly oppositional. In both existing cases, the group had continued to operate beyond the specific crisis that they were established to fight. Although it was suggested that both took a more strategic view than the League of Friends, there was no clear mechanism for these groups to influence decisions beyond moments of crisis. In the other case, however, the group (seen as ‘the community’) had become an established part of a partnership of health and social care commissioners and providers in the local area. Both were set up in response to an initial perceived threat to the future of the community hospitals but had broadened their remit considerably, placing the community hospital at the centre of wider population health plans.

In addition, in some of our cases, community members had opportunities to influence decisions through the appointment of key individuals, often a key member of the League of Friends, to governance positions within health-care trusts.

The general view, however, appeared to be that opportunities for and the abilities of communities to have a say in key decisions regarding community hospitals were limited:

There is no local input at all and I think there should be. You call it a LRG: I would love to have a small LRG and that would at least – not run the hospital – but at least be able to have a say and it could be listened to.

CH1, V01

Underlying some of these tensions was a perception among many respondents that the communities ‘owned’ their hospital (see Chapter 7) and were therefore entitled to have a say in its governance. As actual ownership and associated governance and decision-making structures were perceived to have become more remote and fragmented, communities felt that they had less ability to influence decisions. The ‘community hospital’ was not always managed or governed as a single entity, but as a series of services, each of which might be the responsibility of a different provider.

One of the case studies had, however, addressed this issue directly. When the hospital was closed by the NHS, they raised the funds to buy it, establishing a charity to own and run the hospital, leasing the space to a local health-care trust, which then provided services. They said:

That’s where owning the building came in, because if we owned the building then we had a bit of a say in how it was all maintained. The NHS does the actual caring but we can back it up.

CH7, CY08, FG

Deprivation/privilege

When reflecting on differences in levels of community support, respondents tended to initially suggest that they could be explained by variations in prosperity/deprivation. Analysis of the Charity Commission data89 on League of Friends income, however, shows that the size of income was not significantly related to the level of deprivation in the area [t-test: F(3,3) = 1.94, p = 0.12]. These results are likely to be influenced by the low variability in the level of deprivation across community hospital Leagues of Friends, given that most community hospitals were located in more prosperous areas, but do, nevertheless, suggest that other factors are contributing to these variations.

Geography, rurality and community

With a small number of cases, generalisation is difficult, but the level of engagement and support provided to community hospitals appeared to be influenced by a range of geographical factors including its degree of rurality and isolation. Respondents highlighted long travel times to acute hospitals, poor public transport, the lack of other services, the stability of the local population and the strength of community belonging and resilience as being features of rural or more isolated areas that strengthened the support for the community hospital. The one case study with no League of Friends and very limited community engagement was based in a city, close to the centre, and surrounded by housing. The most frequent interaction hospital staff had with residents was complaining about car parking: ‘So there doesn’t seem to be any great relationship at all to be honest’ (CH4, S03).

The precise location of hospital sites in relation to the centres of population was felt likely to influence local commitment. Visible locations in centres of populations were thought likely to facilitate engagement, in contrast to peripheral sites.

The presence, or otherwise, of other health organisations, charities and community groups within the local area was thought to influence engagement with the hospital in a number of ways, including acting as a source of competition for people’s time and money. More generally, however, it was suggested that hospitals located within communities that had a vibrant mix of voluntary and community groups were likely to have higher levels of engagement. This is consistent with wider arguments about collective efficiency: in some circumstances, voluntary sector diversity has been associated with wider community initiatives.

History

The history of the hospital and the community also shaped engagement. Two case studies were war memorial hospitals that were positively associated with community engagement:

. . . I think the history of the community, with this being a memorial site, I think people within the community have generations of people using their bare hands to build the hospital. So there’s a lot of history and passion in that sense.

CH5, S02

This provided a sense of ownership and also temporal connection to one’s ancestors. For the two case studies that had their origins as workhouses, the legacy was less clear, and one respondent said:

That was the workhouse and it’s got a whole different persona really, it’s got a whole different stigma attached to it.

CH3, S01

This folk memory is interesting given that workhouses were abolished in 1948. It seemed to affect engagement in one community more than another, suggesting the interaction of other factors.

Related to the historic origins of the hospital was the sense of ownership: ‘local people feel this is really their hospital’ (see Chapter 7). Those with a strong sense of ownership of the hospital were more likely, it was suggested, to actively support it:

Well I think it’s because the community built the hospital, I think they significantly put finance in for it, that they owned it, they made it their responsibility and I think that that has been passed from generation to generation. You know, from my great-grandparents right through to me, that this is our local community hospital and we are proud of that.

CH3, S01

Threats to the survival of the hospital were identified as being linked to variations in levels of support. When communities had to fight for the survival of the hospital, or services within it, levels of engagement and support often peaked. One of the case studies, however, suggested that persistent threats to the future of the hospital had ‘caused unsettlement to the community’ that, over time, was weakening support for the hospital.

Range of services

The range of services available within the community hospital, and, subsequently, the numbers and types of patients using those services, was also influential: ‘if it can provide care and service for the whole community, it will have more community support’ (CH7, S11). Particularly influential was the provision of maternity services, end-of-life care and MIUs, through increasing the relevance of the hospital among a broader range of people. In one of the case studies, it was suggested that a narrowing of services, to little more than inpatient beds, coupled with those beds serving an ever-widening geographical area, contributed to a perception that ‘it’s not the community hospital anymore and, therefore, getting support is not easy’ (CH6, V01).

Enhancing hospital sustainability and utilisation

Community engagement had, in some cases, kept community hospitals or, more frequently, specific services open. Indeed, this engagement may be an important factor in the apparent resilience of community hospitals (at least, until recently), as suggested through the stability in their numbers as reported in Chapter 3. This was particularly evident in one of the case studies when the hospital had been closed by the NHS but was subsequently reopened after the community raised the money to buy and run it, as has been noted elsewhere. 102

The significance of community engagement to retaining hospitals and/or specific hospital services was thought likely to increase in the future as the pressures on NHS budgets heightened. The challenges that this may raise in terms of equality of access to health-care services was recognised by some respondents; although the sums are small relative to NHS budgets, there are considerable variations between hospitals.

Community engagement had also contributed to service utilisation in some community hospitals, generally through raising awareness of the hospital and the facilities available there through fundraising activities, or more specifically through running campaigns to improve utilisation of specific services.

The impact of the community on the hospital was, however, far less significant in some cases. In one case study, for example, it was suggested that if the community did not get involved, no-one would really notice, although ‘some of the trimmings might disappear round the edges’. In addition, a tendency towards resisting change was seen by some to be a significant downside of community engagement, potentially preventing important improvements to service delivery.

Contributing to patient and carer experience

Community engagement was seen to affect patient (and carer) experience in a number of ways. Enhancements to the appearance of and equipment within hospitals were agreed to contribute to patient experience and were characterised as ‘the cherry on the cake’, giving them the ‘extra bits which the hospital won’t or cannot afford’, and contributing to the ‘happy atmosphere’ found in most of the case studies.

It was suggested that the physical presence of volunteers in the hospital and onto the wards could ease anxieties about hospitalisation contributing to the ‘known-ness’ and feelings of being ‘closer to home’, reported as key facets of patient experience (see Chapter 5). Intergenerational connections, facilitated through, for example, school children coming into the wards at Christmas, were an additional, beneficial aspect of this and one that patients responded to particularly enthusiastically.

It was suggested that some patients found it easier to talk to volunteers, ‘someone out of uniform’, than to staff or even family members, and this could be an important form of therapy: volunteers could help to tackle isolation, loneliness and boredom, and, more generally, by helping to ‘lift people’s spirits’ and ‘making them happy’.

Community engagement could also be beneficial at the point of discharge, helping to enhance the transition from hospital to home. Relationships with third-sector organisations were seen to be particularly important here, as they could fulfil an important function in enabling safe discharge through, for example, providing befriending services or day care facilities. Leagues of Friends funding had also been used in some hospitals to buy ‘little gadgets and bits and pieces that are making the patients’ discharge and safety better’ (CH5, S11).

Boosting staff morale

Community engagement also had an effect on staff experience: feeling supported and valued by the community was important and, for some, contributed to a distinction between the experience of working in a community hospital and an acute hospital. Community engagement could help boost staff morale as a demonstration of appreciation:

I think the staff feel the benefit of a bit of community involvement, I think they feel supported by the community I would say [. . .] well, I think it’s an encouragement, isn’t it, that they are doing a good job and sort of a morale booster.

CH1, S06

Experiences were not, however, universally positive. Building and supporting community engagement takes time and energy, and some staff reported having to ‘pick up’ tasks when volunteers had not turned up or had not done a job effectively. Some staff also found that community engagement could create expectations that they found hard to manage, such as expectations regarding access to the building (volunteers thinking they had ‘free rein’ of the hospital) and regarding care: that those who actively supported the hospital had a right to be treated there. Some staff felt that they had compromised themselves in bowing to the pressure of such expectations.

Enhancing volunteer well-being

Engaging with the hospital was also found to have outcomes for the volunteers themselves. For some, getting involved in the hospital/League of Friends represented a replacement for paid work: it had eased the transition into retirement, giving them something to do, a structure to their day and a source of satisfaction, identity, pride and status. This was a particular theme for those who were retiring from nursing, enabling them to continue a life-long commitment to health and care. For a small number of respondents, volunteering at the hospital was an alternative to paid work, which they were unable to sustain for varying reasons.

The social interaction and physical and mental activity associated with volunteering at or for the hospital was also important for some, particularly older, respondents. As one respondent said of volunteering for the League of Friends: ‘for me it is like playing bridge: a challenge which I like’ (CH6, V2); another said: ‘I think it’s better than any medicine really.’

However, active engagement in the hospital can encroach on personal and family time and can be experienced as stressful and tiring, particularly for ageing respondents with health problems: ‘eventually you start to run out of steam, or you have a health problem, and it’s very difficult’ (CH6, V03). Equally, when not being well utilised or supported, volunteering was, for some, at times boring or frustrating. Once involved, however, it could be hard to give up: ‘it’s hard to get off the crazy train . . . My husband says he’s going to divorce me if I take anything else on!’ (CH8, V01). For some, there was then a risk of burn-out.

Community life

Beyond the hospital and the individuals involved in supporting it, community engagement was seen to have a positive impact on community life in general. The activities involved in supporting community hospitals, described in the sections above, were building (and were often reliant on) social interaction, networks and trust. Fundraising events in particular, both small (e.g. bingo) and large (e.g. fêtes), were highlighted as important functions in the social calendar of the community by bringing people together and tackling social isolation. This was seen as particularly important for older people within the community, with the additional benefit that an absence at a regular bingo night, for example, would be noted and followed up to check on the person’s well-being. Part of the value of the community hospital to the community, which the following chapters go on to discuss, comes through the engagement and community action that it engenders.

Local services

Community hospitals were valued as providers of ‘an essential service’ that was perceived as being ‘desperately’ needed. The instrumental value of community hospitals as providers of a range of local and accessible health (and often social) care services was invariably cited first by respondents, but was seen as going beyond the individual patient and carer experience reported in Chapter 4 (and, therefore, not repeated here). As summarised by one respondent: ‘there’s a lot of that social value that can be added from us being closer to home’ (CH4, S01). The value of providing local health-care services was heightened, it was suggested, in more remote, rural areas and for older people, people with learning disabilities or mental ill health, those with degenerative long-term conditions and those at the end of life. This is an argument for decentralisation and accessibility of health care rather than for the precise form through which services are delivered.

This was argued in psychological terms, somewhat overlapping with the symbolic benefits of the institution (see Institutional presence, identity and belonging), such as the deep feeling of reassurance and safety it provided for many community members. The following words were used regularly in discussions regarding the value of the hospital to respondents: ‘security’, ‘life line’, ‘peace of mind’, ‘a safety value’, ‘confidence’, ‘comfort’, ‘reassurance’, ‘safe haven’, ‘sanctuary’, ‘arm around the shoulder’. The presence of a hospital provided this sense of security, irrespective of actual or potential use by individual respondents: ‘it’s a safety blanket basically’. This was felt to have additional associated tangible benefits, including enabling older people to stay in their own homes for longer as they felt confident in the knowledge that a hospital was close by should they need it.

There was a suggestion that the depth of reassurance and security provided was enhanced through the historic continuity of a hospital within its community. The converse of the security provided by the presence of the hospital was a fear of its closure:

You’d say ‘thank God it’s there’, because, I mean, you never know when these things are going to happen . . . you know they’re always here and you just pop up, even though you’ve got to be prepared to wait. But it’s like a lifeline really. I couldn’t imagine if it closed. Well, I think everybody would die overnight. They’d be terrified of this place closing.

CH1, CA01

Local economy and employment

Community hospitals also had a more direct economic value as local employers, providing opportunities in places where ‘most of the work had dried up’. This points to perceptions of economic vulnerability because of the decline of other sources of employment associated with rural areas. In terms of staff numbers, community hospitals are small or medium-sized enterprises.

Looking beyond numbers, community hospitals were seen to provide valuable, convenient, high-quality, satisfying employment (although it is important to note that it was also often pressured, stressful and sometimes isolating). Many of the staff to whom we spoke, from hotel staff to assistants, therapists, nurses and doctors, were passionate about their community hospitals: ‘it has been my career and I have loved it. I have been here all this time and I love this place to pieces’ (CH5, S04). The scale and local orientation of community hospitals were compared favourably with those of acute hospitals, with one respondent suggesting that working in a community hospital was ‘what nursing is all about – it’s about proper hand holding, it’s about what every nurse in her heart should be able to do still and some people forget about’ (CH6, S01).

The value attached to the work was intensified for those working close to home. Not only were staff more likely to know each other and their patients outside work, they were also likely to be users of the hospital services themselves. This heightened their attachment to the hospital, contributing to a sense of wanting to work hard to provide the best possible service, to the point where ‘. . . we then do the extra mile [sic.]: we will put in extra shifts, we will stay after shifts . . .’. As one respondent put it:

. . . it is pride in what you provide, because you are walking, you are bumping into people on the street that know that is where you work and you want them to be pleased [. . .] it is providing a service for locals that they are proud of and you are proud of.

CH7, S11

Economic contributions extended beyond employment and had a positive impact on the wider economy and ‘economic well-being . . . people going to a MIU and coming away are at work quicker’. Particular mention was made of their contribution to agriculture (relatively high-risk work with a need to return to work quickly) and tourism (reassurance for visitors). Historical research suggests that such instrumental motivations were certainly in the minds of hospital founders. It was also suggested that having a community hospital may attract people to move into an area, and as one respondent stated: ‘one of the things that drew us here was the hospital’.

Social economy and community ecology

The presence of a community hospital also has an impact on the wider social economy and the network of voluntary and community groups operating in the area. The most visible manifestation of a contribution to social value was that community hospitals provided a base for the activities of community organisations. As well as many instances of free use of hospital space for meetings, examples included a community hospital kitchen providing catering services for a local charity, a charity worker being co-located with a community team within a community hospital and charities being physically based on hospital premises. Institutional presence was crucial to one community transport organisation because the hospital staff supported it through holding keys for drivers out of office hours; this enabled the organisation to extend it services: ‘for our user groups to have access to the buses 24 hours a day, 7 days a week, 365 days a year’ (CH4, CY03).

It may be stretching the evidence to suggest that without the presence of the hospital these activities would not take place, but, by being focused on the institution, they facilitate the strengthening of social networks, and if the hospital was not there, groups would have to find alternative, and potentially more expensive, places to meet.

Assets and ownership

When asked about the value of hospitals to the communities within which they were based, many respondents argued that it was a ‘key community resource’ or ‘a huge asset’. Such views were underpinned by a strong sense of ownership of community hospitals by their communities, regardless of formal legal ownership. Here, respondents drew on repositories of knowledge concerning community initiative in establishing the hospital, the symbolism of institutions whose physical presence memorialised those fallen in war and a sense that the hospital united all members of the community, particularly by bridging generational gaps. The following is illustrative of such views, with a respondent explaining that support for the hospital was:

. . . because the community built the hospital for themselves. I think all that time ago, I think they significantly put finances in for it, they owned it, they made it their responsibility and I think that that has been passed from generation to generation. You know, from my great-grandparents right through to me, that this is our local community hospital and we are proud of that, and that we each should support it.

CH3, S01

It was also associated with a sense of entitlement among some community members to have a say in how the hospital was run, with one respondent claiming that some elderly residents were unaware that the hospital had been transferred to public ownership on establishment of the NHS, so that:

. . . they still have that firm belief – ‘this is our hospital. We don’t want to lose it. We get a choice’. And they should get a choice because it is their community hospital, whether they own the building or not any more it makes no difference. It is their community hospital and it’s so evident[ly] the feeling of everybody in the community, even young people.

CH5, S05

It does seem implausible that someone interviewed in 2016 would have been unaware for seven decades that the hospital was no longer in voluntary hands, and perhaps what is being referred to here accords more with the lack of awareness of recent organisational change in the NHS:

I thought that we owned the land? And I thought they owned the . . .

No, it was taken over, the whole thing, in 1948, it became government property and it was in the local administration’s management. But about a year ago, this trust was set up called NHS Property [Company], that own all NHS property.

Even though the [local community] residents raised the money in the First World War for the hospital to be . . .?

That doesn’t wash.

CH5, V03, FG

However, there was also evidence that a sense of community ownership had survived shifts in legal ownership, not to mention the many changes in service providers and workers:

So, the ownership by League of Friends and local population is, you know, I always say they’re the ones that kind of own the hospital in a sense. I always do the analogy of a football club in that the manager can change, the players change, the stadium changes, the board has taken over but the fans stay . . . committed to the club even though everything else changes . . .

CH1 and 2, T02

The issue of ownership, however, became contentious when the community hospital was under threat of closure or significant change. In some of the hospitals, recent changes, including changes in ownership, provider, services and/or patient mix, which the community themselves felt they had little control over (see Chapter 7), had contributed to an erosion of the sense of community ownership and value:

So what I’m saying is, if you are interested in the connection between the village and the surroundings and the hospital, then the emotion connection is very much diminishing [. . .] It’s because it is not a cottage hospital any more.

CH5, V01

Institutional presence, identity and belonging

Beyond the instrumental and social value of providing local health-care services, however, community hospitals had important cultural and symbolic value. It was suggested that they embodied and were a visible demonstration of shared, communal values:

It’s a site of remembrance and it’s a site of sort of practical help for the community in helping its most vulnerable members, people who are injured and who are sick.

CH5, S14

They provided a common point of reference and a physical site through which individuals, families, groups and organisations came together:

It’s one of the central points that makes up the town and the community. And also gives us a very essential, local feeling. It’s part of the glue that makes up the whole community.

CH1, P06

At least one of the hospitals, for example, holds an annual World War memorial service, bringing together patients, staff, the church and other members of the community: an important symbolic and social event. When combined with the fundraising activities organised by the League of Friends, some hospitals become important facilitators of routine social interaction, ‘contributing to the social life’, within their communities.

Thus, they ranked alongside other important local institutions (almost regardless of the specific services they provided), such as churches, schools, banks and libraries. They were focal points within their communities and their presence was seen as an indicator of the viability of the community:

. . . it’s a very important pillar, along with, say, the bank and the building society and everything else that goes with it. It’s a good thing for morale, I think, for the area to have such an organisation.

CH8, CY03 FG

This was particularly so in rural, isolated communities and/or communities that had experienced economic decline and an associated loss of services:

And people are, you know, they are very emotionally attached to it because they see pubs closing and they see shops closing and I think to close hospital beds, they see it as a nail in the coffin.

CH9, S08

For these reasons, many respondents had strong emotional attachments to their community hospitals and even stronger emotional responses to any threat to their future. Words such as ‘pride’, ‘love’, ‘hope’, ‘trust’, ‘passion’, ‘anguish’, ‘anger’, ‘sadness’, ‘distress’ and ‘fury’ were frequently used.

One respondent went as far as to say: ‘I cannot really put it into words really. I would fight to the death for it. I would’ (CH8, CA03). Such emotional responses were reflective of the significant ways in which hospitals were valued for their contribution to a collective sense of identity, to a sense of place and belonging: not only could they provide an important service, they could ‘define the community’.

Again, this was particularly so, it was suggested, for more isolated rural communities and those that had experienced decline, where any remaining ‘pockets of ownership mean an awful lot’. In such contexts they were, it was suggested, fundamental to ‘a sense of place’. This could, on occasion, be mobilised in service of the collective goal of retaining the hospital. In one community in particular, the previous loss of several services added to a conviction that they must fight to save the hospital when it was threatened with closure: ‘that was the last straw’. Fighting a successful battle to retain the hospital (even though some questioned whether or not it was ever actually under threat) had the dual benefits of maintaining local health-care services while also boosting local ‘civic pride’ and feelings of ‘resilience and autonomy’.

Implications for system planning (i.e. sustainability and transformation plans)

Adopting a localised approach to health service planning, for example through STPs, offers considerable potential for devolved decision-making, but carries strategic risk. There is a danger that the combined impact of proposed changes to community hospitals across the country may be obscured. This risk is heightened by the notable lack of any national policy for community hospitals.

This study has highlighted both the diversity of community hospitals but also their points of commonality, including the role they play in providing local, accessible, intermediate health care; the valued embedded, relational model of care that they provide; and the significant community value they represent. Questions have been raised, however, as to the power of existing evidence of either patient experience or community value to temper financial rationales that are perceived to be dominating discussions about the future of community hospitals. Unduly privileging financial imperatives risks underestimating or undermining other forms of value. Future plans should be based on a sophisticated analysis of not just the economic costs and benefits of community hospitals, but also their community value, which encompasses individual, collective, instrumental, economic, social, human, cultural and symbolic costs and benefits.

The feelings of ownership that communities often have over their community hospitals suggest considerable potential, and, indeed, expectation, if not obligation, to involve them in the design and delivery of services. Existing consultation mechanisms often appear insufficient, leading to frustration on both sides, and meaningful coproduction was the exception rather than the rule. There is a tension between the scale at which communities appear to want to engage, making decisions about ‘their’ community hospital or ‘their’ community’s health care, and the scale at which engagement activities are currently often focused (i.e. at a wider geographical or system level).

The attraction of new models of care focused on supporting patients in their own home (increased financial savings and clinical safety) appears to underestimate both the lack of social care funding available to facilitate this strategic change and the lack of alternative community bed provision (e.g. nursing homes, residential care homes and hospices) for people unable to return home after an acute inpatient admission. Community hospital beds continue to play an important part not only in step-down care, but also in acute admission avoidance (step up) and effective generalist provision for addressing the multiple comorbidities prevalent in older people. The potential to expand their role in both acute attendance avoidance and broad preventative agendas appears significant.

The increasing pressure on acute hospitals and the growing acuity of patients is presenting a number of challenges for community hospitals (including the level of medical cover available, skills of nursing staff, longer lengths of stay, more pressure to discharge). There is some evidence that this is resulting in inappropriate referrals and patients being bounced back to acute hospitals or staying in community hospitals for longer than would otherwise be necessary. When combined with pressures on social care that are having an adverse effect on community hospital discharges, the process is acting as an ineffective shifting of the (acute hospital beds) problem.

Implications for community hospitals

Community hospitals provide a distinctive and valued model of care that is both relational and embedded. They are flexible and agile in their response to changing demands and are generally supported and valued by the communities from which they originate, within which they are based, from which they draw their staff and to which they provide service and care. Although the mapping work undertaken through this study has provided greater clarity on the characteristics of community hospitals, it is these deeper points of distinction that were highlighted by respondents and stand out as being worthy of particular emphasis.

Community hospitals, however, are changing and are already diverse. Although the story of community hospitals has always been one of evolution, the pace and scale of the changes they are currently experiencing, including the withdrawal of GPs, the fragmentation of provision, the shift towards step-down care, the associated increasing acuity and decreasing localness of inpatients, the questions being raised in some areas of the future of inpatient beds and the wider financial and demographic pressures, could represent a significant cross roads. The erosion of community hospital-level management and governance structures represents a particular challenge for navigating these complex external developments at the local level and reduces the potential for both integrated working and patient or community involvement in service design or delivery.

Community hospitals provide an embedded, relational model of care within which the functional, social, interpersonal and psychological aspects of patient experience are all integral. Each of these aspects requires attention, not least because each can be moderated by external and internal factors that may undermine the overall model of care. A particular challenge identified was attending to patients’ psychological health. Although patients were generally far less anxious about attending a community hospital than an acute hospital, admission to hospital was often associated with a significant life transition, potentially generating anxiety and depression, yet clinical attention to psychological, emotional and mental health needs was not consistent and represents an area to be addressed.

Communities do a lot to support their hospitals, and the contribution of volunteers and voluntary income can have a significant impact. There are, however, considerable variations in support both across and within communities and over time. Although support for community hospitals is generally widespread, active, regular engagement is often limited to a relatively small and select group of community members and voluntary income (and membership) is on the decline. The potential to do more to enable and support active community engagement was recognised, but often without any clear idea of how to do so. Converting the more widespread, yet more passive, support into more regular, active engagement – beyond moments of crisis – requires time, energy, enthusiasm and, inevitably, money. The case studies suggest that mobilisation is difficult, but that in the right circumstances it can be achieved. This may mean more actively supporting Leagues of Friends in their efforts; it may mean developing a range of structures to facilitate and support wider forms of engagement.

In addition to the above implications for community hospitals as a whole, each of the participating case study community hospitals has received an individual presentation and report of the findings specific to their hospital within which specific implications for each were discussed.

Implications for patients, carers, communities and Leagues of Friends

Community hospitals are widely valued by patients, their families and communities. They are, however, changing, at the same time as communities are also changing, and their contribution to community life can change over time. In particular, a number of current developments are beginning to change perceptions of the value of some community hospitals to their communities. Although much of this may feel out of the control of individual patients, their families or community members, there is evidence from this study that when communities engage in supporting their hospitals not just through practical voluntary action but also through strategic action within decision-making processes, the value of community hospitals can be not only retained but enhanced.

Leagues of Friends make a significant and valued contribution to the hospitals they support and their wider communities. The individuals involved make considerable personal investments, demonstrating significant commitment and loyalty, often over generations. The challenge of maintaining membership and broadening active engagement, particularly among younger generations, was, however, widely recognised. Getting new people involved may require new ways of thinking and working, both in terms of finding new ways to ask a more diverse range of people to get involved and new activities to involve them in.

Concerns were expressed that the understanding that has informed community fundraising for the NHS for most of its history, namely that funds raised be dedicated to supporting patient and staff amenities or comforts, was in danger of being breached. For instance, we found examples of the use of charitable income to employ staff or purchase equipment for clinical use. Even though the sums involved were generally not large, this raises issues of equity and, more broadly, the appropriate balance between statutory responsibility and voluntary initiative.

Sample

Community hospitals were identified as described in detail in this report, providing a list of 274 hospitals in England and 21 in Wales. We then identified those charities that provided charitable and voluntary support to those organisations. In the majority of cases, these are individual entities often including the phrase ‘league of friends’ or similar in their title. Community hospitals in England may also receive financial support from the NHS trusts’ charitable funds (in England). However, these trust-wide charities usually cover large geographical areas, such as a multisite trust across a whole city or county. It is impossible to identify from these charities the voluntary resources that go to support a particular community hospital. We therefore excluded such institutions from consideration.

To locate non-registered charities (usually those with an income of < £5000 a year) and to link them to community hospitals, we employed two methods. First, we involved Attend, a national charity that supports voluntary organisations promoting healthy communities. Second, we contacted community hospitals on our list and enquired as to whether or not they have a supporting charity and, if so, what were its contact details.

We approached eight non-registered organisations with an income of < £5000 a year directly for copies of their annual reports in order to capture data from them. However, two of these did not have up-to-date contact details and only two of the remaining six charities responded to our request. We therefore did not use these data in our analysis.

In one case, one charity supported three local community hospitals. To avoid counting its financial contribution three times, it was linked to just one of those hospitals and, therefore, included in our sample only once.

As a result, financial information for at least 1 year between 1995 and 2014 was available for 245 charities in England and that formed the final sample for this part of the analysis. The number of non-zero financial reports to the Commission in this period ranged from 181 to 226; note that the data for the 1990s are known to be incomplete because of problems with the old electronic media from which they were recovered, and there is no definitive backup of the data. The data from 1997 onwards are available for a broadly stable population of organisations. The 2014 data were those available at the time of analysis (2016): there is a time lag in the availability of data as a result of the processes of (1) charities themselves producing their annual accounts, (2) the Charity Commission then processing returns and adding them to their database and (3) the supply of the data to researchers and its integration into their own databases.

Financial contribution: total income and total expenditure

All financial figures for 1995–2013 were adjusted for inflation using the Office for National Statistics’ annual retail price index;125 therefore, all financial information is presented at constant 2014 prices.

Detail of income and expenditure

Charities’ accounts are published on the Charity Commission website, typically for the preceding 5 or 6 financial years, if their income or expenditure exceeds a threshold of £25,000. Using this, we obtained copies of these accounts covering 397 separate financial years; after the exclusion of Wales, the number of accounts available are presented in Table 24.

We have focused on the period 2008–13, for which between 41 and 91 charities of interest generated at least one such financial return. This variation is for two reasons: individual hospitals may or may not reach the threshold of £25,000 in any given year and, even if they do, they may not always submit copies of their accounts as requested. Capturing more recent financial data was not possible for a further reason, namely that there is usually a delay between a charity submitting its reports and accounts and the material being processed and published by the Charity Commission.

Charity accounts provide relatively little detail on income and expenditure and may even aggregate what are quite different sources of expenditure within the same funding stream. For example, a health charity may record, under the general heading of ‘income from charitable activities’, both fees paid by individuals themselves directly (e.g. for private consultations or treatment) and payments made under contract by a CCG. Technically, both payments to the charity are for services rendered; substantively, the two are distinct.

In order to probe income sources and the application of expenditure in more detail, data from the notes to these charities’ accounts were captured by the Centre for Data Digitisation and Analysis at Queen’s University Belfast. This generated 21,773 items of data, or an average of 54.9 items per set of accounts captured. The data are characterised by a text description of either the income source (e.g. ‘legacy from estate of J. Smith’; ‘proceeds of hospital fête’) or the expenditure (e.g. ‘purchase of television for ward X’, ‘costs of running hospital fête’). In order to get beneath the rather aggregated categories used by the Charity Commission, these items were classified by our research partners, the NCVO, using established automated Bayesian matching techniques. These procedures scan the text and compare it with previously captured data (with some 10 years’ experience of classifying approximately half a million lines of text data per annum, the library of text against which new data are being compared is very comprehensive). The aim is to identify the most plausible match.

The data provide useful insights, although it can be argued that each set of charity accounts is unique, because there are variations between accountants in the interpretation of the financial data available to them. Indeed, we ourselves encountered exactly this problem when comparing presentation of financial information in two of our case study sites. Although broadly comparable in terms of levels of expenditure, one charity presents a great deal of detail for relatively small amounts of expenditure, whereas the other aggregates most of the charitable expenditure into a small number of categories.

Classifying the expenditure of charities has not been attempted because it is time-consuming, and not very informative. Some 6700 lines of expenditure are recorded in our data and, of these, there are nearly 2000 unique descriptions of the subject of the transaction, and nearly two-thirds of these occur fewer than five times. The items that occur most frequently include general categories, such as ‘direct charitable expenditure’ or just ‘expenditure’. Neither is particularly informative.

Volunteer contribution: number of volunteers and estimates of volunteer input

According to the Commission’s guidelines126 for reporting the number of volunteers, charities must provide their best estimate of the numbers of volunteers involved in their activities via their annual returns. There may be differences between charities in how they define a volunteer, but they are commonly understood to encompass people who contribute to the charity’s objectives in a voluntary and unpaid capacity (though legitimate expenses may be paid). The decision on who to count as volunteers is left to the discretion of the trustees of the charity

Prior to 2013, data on numbers of volunteers were often sparse, but since that date, efforts have been made to gather more detailed information. We have data for 106,000 charities; these were derived from over 320,000 separate returns, some of which went back a number of years. However, approximately 73,000 charities had supplied between one and three non-zero returns of the counts of their volunteers in the 3 years between 2013 and 2015. We summed the total for each charity and divided it by the number of years for which we have a return. Thus, a charity with 175 volunteers, which had made five financial returns, will be regarded as having, on average, 35 volunteers. To provide an upper-bound estimate we also calculated the maximum value returned for each charity over the period in question. The data on volunteer numbers for community-related League of Friends are significantly more comprehensive than for the charity population as a whole. We have numbers of volunteers for nearly 90% of these entities compared with approximately 64% for charities generally.

Volunteer hours were estimated using regular survey data (Home Office Citizenship Survey, 2001–2010; Community Life survey, 2012 onwards). We take the average number of hours per week reported by those who say they have given unpaid help to organisations during the previous year. This is approximately 2.2 hours. This is a minimum estimate and it may be that the actual numbers are larger than this would imply. If we make the assumption that these are probably fairly regular volunteers, a higher figure of 3.05 hours per week is given if we take the average number of hours reported by those who say they volunteer either at least once a week or more frequently, or at least monthly but less frequently than once a week.

There are no studies that would tell us with any certainty whether or not volunteers in these kinds of organisations put in more, or fewer, hours than the volunteering population generally. Two widely quoted studies (Galea et al. 43 and Naylor et al. 42), which estimate that there are around 3 million volunteers in health and social care, do not allow any inferences to be drawn about the settings in which such health-related volunteering takes place.

We then multiplied these two estimates of time inputs by the average and maximum volunteer numbers, respectively, to give the number of hours contributed by volunteers over the course of the year (assuming 46 weeks’ volunteering). These can be converted to full-time equivalent numbers by dividing back by 37.5 and 46.

Opinions differ on the best method for calculating a cash equivalent for the value of volunteer labour. The lowest is to use the national minimum wage; others might include an estimate of the replacement cost (i.e. what it would cost the organisation to employ people to do the same tasks if they had to pay them), but this assumes knowledge of the tasks being undertaken. The national minimum wage for the period for which we have the most comprehensive volunteering data (2013–15) was £6.50. 91