Article

Contribution of general practitioner hospitals in England and Wales

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Abstract

A survey of a one-in-seven sample of general practitioner hospitals in England and Wales, performed to determine the contribution they make to overall hospital work load and the attitudes of the general practitioners working in them, showed that 3% of acute hospital beds in England and Wales were in general practitioner hospitals, which provided initial hospital care for up to 20% of the population. Altogether 16% of general practitioners and 22% of consultants were on the staffs, and they coped with more than 13% of all casualties, 6% of operations, and 4% of x-ray examinations. Nearly a million casualties were treated at no cost to the National Health Service. Twenty new district general hospitals would be needed to cope with the work load currently dealt with by general practitioner hospitals. The results of this survey indicate that these smaller hospitals deal efficiently and cheaply with their work load, and that morale is high. General practitioner hospitals could have an important part to play in providing certain types of care, but there are no financial incentives to enable general practitioners to realise this potential fully.

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... Cavenagh (6) showed that in the late 1970s, for England and Wales, community hospital services equated to 20 District General Hospitals and that 16% of GPs were involved in their local hospitals. A subsequent UK wide study in 2000 found that this was higher at 20%, at a rate of 1 in 5 GPs (7). ...
Article
Background GPs were a key driving force for the development of a network of community hospitals across England and have provided medical cover for most. The past decade, however, has seen a significant shift, with the dominant trend appearing to be one of declining GP involvement. Aim To explore how and why the role of GPs within community hospitals in England is changing. Design and setting. Qualitative study in a sample of nine, diverse, community hospitals in England. Method Qualitative interviews with community hospital clinical staff. Results 20 interviews were conducted and two models of medical care observed-GPs employed by a practice and Trust employed doctors. Interviewees confirmed the trend towards declining GP involvement with identified factors driving change being: GP workload and recruitment challenges, a change from ‘step-up’ admissions from the community to ‘step-down’ admissions from acute hospitals, fewer local patients being admitted, increased medical acuity of patients admitted, increased burden of medical support required and inadequate remuneration. The majority of doctors viewed community hospital work in a positive light welcoming the opportunities for personal development and acquiring new clinical skills. GPs viewed community hospital work as an extension of primary care adding to job satisfaction. Conclusion Multiple factors have driven changes in the role of GP community hospital clinicians. The NHS needs to develop a focused strategy if GPs are to remain engaged with community hospital work. Key words General practice, community hospital, intermediate care, primary care, qualitative research
... care, rehabilitation, observation and assessment, and respite and palliative care (6)(7)(8). At this time, however, little is known about the severity of illness and the healthrelated quality of life (HRQOL) of patients who are admitted to these GP hospitals (9). ...
... [1][2][3] Ofschoon er maar weinig onderzoek naar de zorg in deze klinieken is uitgevoerd is het aannemelijk dat ze met name voor oudere patiënten de druk op ziekenhuisbedden kunnen verminderen 4-5 en een functie kunnen vervullen in acute klinische zorg, revalidatie, observatie en onderzoek, terminale zorg en zorg ter ontlasting van de mantelzorgers ('sociale indicatie'). [6][7][8] Evenmin is er veel bekend over de ernst van ziekte en kwaliteit van leven van patiënten die in deze klinieken worden opgenomen. 9 Wij beschrijven in dit onderzoek de eerste huisartsenkliniek (HAK) in de Nederlandse gezondheidszorg aan de hand van de kenmerken van opgenomen patiënten. ...
... GPs are usually seen as the medical professionals most involved in providing care. However, studies in the UK indicate that just 15-20% of GPs are involved in CHs (Cavenagh, 1977;Seamark et al 2001). Interestingly, a recent survey of Irish geriatricians found that almost two thirds reported having regular CH visits (O'Hanlon and Liston, 2009). ...
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Community hospitals provide many services for older people. They are mainly managed by nursing staff, with some specialist input. Little is known about education provided in these facilities. Most education in geriatric medicine is provided in hospitals, despite most elderly care being provided in the community. The authors surveyed senior nursing staff in Irish community hospitals to examine this area in more detail. Staff in all 18hospitals in the Health Service Executive (South) area were invited to participate. The response rate was 100%. Sixteen of the 18 respondents (89%) felt staff did not have enough education in geriatric medicine. Just over half of hospitals had regular staff education sessions in the area, with a minority of sessions led by a geriatrician, and none by GPs. Geriatrician visits were valued, but were requested only every 1-3 months. Staff identified challenging behaviour and dementia care as the areas that posed most difficulty.
... Beyond these local social and financial advantages lie benefits for individual general practitioners and for general practice. Although there are few financial incentives to undertake work in the general practitioner hospital, it is clear that general practitioners find the work attractive in itself (Evans, 1969; Cavenagh, 1978). They are allowed to practise clinical skills which might otherwise atrophy, and contact with hospital colleagues encourages them to keep knowledge and skills up to date. ...
Article
Admissions during 1980 to a hospital staffed by general practitioners are analysed. Almost all (94 per cent) were acute admissions. The mean length of stay was 11.7 days and the mean age of the patients 63.3 years, with 40 per cent of them under 65 years of age. Two thirds of the patients were discharged to their homes and only 7 per cent of patients spent more than four weeks in hospital. General practitioner hospitals have medical, social and economic advantages over large district hospitals for certain acutely ill patients and have an important role in primary medical care.
... The economic value of encouraging consultant outpatient clinics to be held in general practitioner hospitals has been shown convincingly by Gruer (1971); the undoubted additional advantages of convenience, less travelling, local nurses known to the patient, and increased general practitioner/consultant communication remain. Cavenagh's (1978) recent survey of general practitioner hospitals shows well the significant contribution that they make to the hospital workload. He also gives the estimate that 20 district general hospitals would be needed to cope with the workload if all general practitioner hospitals were phased out. ...
Article
For a period of six months a record was kept of every attendance at a general practitioner hospital by a patient from a four-partner practice with a list of 10,500 patients.During the six-month period one in 17 of the practice population was x-rayed; one in 50 attended the physiotherapy department, and the rate for general practitioner surgery consultations was one per person.I believe that in semi-rural North Yorkshire the general practitioner hospital has a continuing role to play and such a hospital can provide a better and more comprehensive service to patients, and give professional satisfaction and stimulation to the primary health care team.
... This has previously been suggested in several studies. [5][6][7][8][9][10] According to estimates from a hospital medical department of Finnmark, 5 patients from municipalities with a GP hospital occupied 0.38 bed days per inhabitant per year compared with 1.19 bed days from the general hospital municipality. In Oxfordshire the rate of use of medical and geriatric beds in general hospitals by practice populations with access to general practitioner beds was about half that of populations without such access. ...
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To assess whether populations with access to general practitioner hospitals (GP hospitals) utilise general hospitals less than populations without such access. Observational study comparing the total rates of admissions and of occupied bed days in general hospitals between populations with and without access to GP hospitals. Comparisons were also made separately for diagnoses commonly encountered in GP hospitals. Two general hospitals serving the population of Finnmark county in north Norway. 35,435 admissions based on five years' routine recordings from the two hospitals. The total rate of admission to general hospitals was lower in peripheral municipalities with a GP hospital than in central municipalities without this kind of institution, 26% and 28% lower for men and women respectively. The corresponding differences were 38% and 52%, when analysed for occupied bed days. The differences were most pronounced for patients with respiratory diseases, cardiac failure, and cancer who are primarily or intermediately treated or cared for in GP hospitals, and for patients with stroke and fractures, who are regularly transferred from general hospitals to GP hospitals for longer term follow up care. GP hospitals seem to reduce the utilisation of general hospitals with respect to admissions as well as occupied bed days.
... Around one in five GPs are involved in community hospitals work compared with Cavanagh's estimate of 15% of English and Welsh GPs in the late 1970s. 4 An Occasional Paper issued in 1990 indicated that 15% of GPs in the UK were involved in community hospitals. 3 Intrapartum obstetric services were identified in 74 (16%) of the UK community hospitals. ...
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There is a lack of basic information regarding the numbers of and facilities offered by community hospitals. This survey identified 471 community hospitals in the United Kingdom containing 18,579 beds with 20% of general practitioners having admitting rights. The majority of hospitals provide a comprehensive range of rehabilitation services and consultant outpatient clinics. Community hospitals are potentially an important resource in providing intermediate care in the community.
Article
Background: GPs were a key driving force for the development of a network of community hospitals across England, and have provided medical cover for most of them. However, during the past decade there has been a significant shift, with the dominant trend appearing to be one of declining GP involvement. Aim: To explore how and why the role of GPs within community hospitals in England is changing. Design and setting: Qualitative study in a sample of nine diverse community hospitals in England. Method: Qualitative interviews with community hospital clinical staff. Results: In all, 20 interviews were conducted and two models of medical care observed: GPs employed by a practice and trust-employed doctors. Interviewees confirmed the trend towards declining GP involvement, with the factors driving change identified as being GP workload and recruitment challenges, a change from 'step-up' admissions from the community to 'step-down' admissions from acute hospitals, fewer local patients being admitted, increased medical acuity of patients admitted, increased burden of medical support required, and inadequate remuneration. The majority of doctors viewed community hospital work in a positive light, welcoming the opportunities for personal development and to acquire new clinical skills. GPs viewed community hospital work as an extension of primary care, adding to job satisfaction. Conclusion: Multiple factors have driven changes in the role of GP community hospital clinicians. The NHS needs to develop a focused strategy if GPs are to remain engaged with community hospital work.
Article
The results of a prospective analysis of one year's surgery on inpatients in a busy community hospital showed that a high quality of surgery may be achieved with safety and low rates of complications. The results of a retrospective analysis of certain aspects of surgery was just as en? couraging. Surgery that is performed in a community hospital is convenient for the patient, provides continuity of care by the general practitioner, and waiting list times are short. Surgical facilities can form an integral part of the comprehensive service provided by a com? munity hospital and can lighten the caseload for minor surgery at the district general hospital. Close liaison between the two hospitals is essential.
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Inleiding: Bij de sluiting van het voormalige Zeewegziekenhuis te IJmuiden in 1996 ontstond een bijzonder transmuraal experiment: de huisartsenkliniek. Hierin kregen de huisartsen van de RHV-IJmond ondersteund door 24-uurs verpleegkundige zorg, de medische regie over de klinische afdeling met 20 bedden ten behoeve van de behandeling van eigen patiënten, postoperatieve patiënten in het laatste deel van hun revalidatie en specialistisch uitbehandelde patiënten met een verpleeghuisindicatie. Doel van dit onderzoek was met name het type patiënten te beschrijven dat door de huisarts werd opgenomen en de rol te onderzoeken die de huisartsenkliniek zou kunnen spelen in de substitutie van zorg. Methoden: Prospectief observationeel onderzoek van alle patiënten die tussen 1 juni 1999 en 1 juni 2000 werden opgenomen met behulp van dossieronderzoek, vragenlijstonderzoek naar de kwaliteit van leven (SF-36) en ADL (GARS), een vragenlijst voor de huisartsen over de ernst van ziekte (Duke Severity of Illness Checklist) en over de keuze voor een andere zorgsetting indien de huisartsenkliniek niet beschikbaar was geweest. Resultaten: In totaal werden 218 opnames geregistreerd. Deze werden verdeeld over de genoemde 3 bedcategorieën: huisartsenbedden (n=131), herstelbedden (n=62) en verpleeghuisbedden (N=25). De gemiddelde leeftijd van alle patiënten was 76 jaar. Belangrijkste opname-indicaties waren: immobilisatie na een val (huisartsenbedden), revalidatie van een botbreukoperatie (herstelbedden) en een beroerte (verpleeghuisbedden). Zonder huisartsenkliniek waren de patiënten op de huisartsenbedden bijna gelijkelijk verdeeld geweest over de thuis-, verpleeghuis- en ziekenhuiszorg. De ziektescore bij opname was voor de patiënten die anders naar het ziekenhuis waren verwezen significant hoger dan voor de andere twee zorgalternatieven. De kwaliteit van leven was voor alle patiënten bij opname laag tot zeer laag. Conclusie: De huisartsenkliniek te IJmuiden lijkt een waardevolle substitutie van zorg te kunnen leveren voor zowel thuis-, verpleeghuis- en ziekenhuiszorg, met name voor oudere patiënten die behoefte hebben aan kortdurende verpleegkundige en medische zorg. (aut.ref.)
Article
A postal questionnaire was sent to a stratified random sample of 33.6% (556 out of 1655) of health workers representing five occupational groups in the Ratnapura Health Region, Sri Lanka, to discover their intensity of job satisfaction.The overall response rate was 60.3% (335 out of 556), being highest among the nurses (P < 0.01) and lowest among the medical practitioners (P < 0.001).Of the respondents, 70.0% (237 out of 335) were generally satisfied with the occupational environment. For 14.8% (26 out of 175) of the minor employees it was ‘excellent most of the time’ and for 19.6% (11 out of 56) of midwives it was extremely uncongenial. The immediate supervisor was described as ‘fair at all times’ by 50.4% (169 out of 335); being 61.7% (108 out of 175) among the minor employees and 21.4% (8 out of 37) among the nurses.Community relationships were described as ‘satisfactory’ by 46.5% (156 out of 335); this being 26.3% (88 out of 175) among the minor employees and 56.2% (18 out of 32) among the middle technical officers. The fellow workers were described as co-operative by 34.1% (114 out of 335) and as ‘all right’ by 34.9% (117 out of 335).Thirty seven per cent (124 out of 335) declared that their personal problems were not affecting their work and 20% (67 out of 335) gave the reply as ‘absolutely no’. The latter reply was highest among the medical practitioners (28.6% or 10 out of 35) and nurses (27.0% or 10 out of 37) respectively.About the factors affecting work, more medical practitioners (57.1% or 20 out of 35) and nurses (67.6% or 25 out of 37) were concerned about staff shortages; more middle technical officers (40.6% or 13 out of 32) and minor employees (37.7% or 66 out of 175) were worried about inadequate incentives and more midwives (50.0% or 28 out of 56) and minor employees (34.8% or 61 out of 175) were not happy with their poor pay. The health department was described as ‘decidedly the best of all government departments’ by 43.3% (76 out of 175) of the minor employees and as ‘better than most other government departments’ by 56.8% (21 out of 37) of the nurses, while 54.4% (19 out of 35) of the medical practitioners failed to find any differences between the health sector and other government sectors.The majority (62.1%) have expressed job satisfaction. Respondents' views on occupational environment, immediate supervisor, community relationships, personal problems and key factors affecting work performance were very significantly diverse among the difference occupations (P < 0.001).
Article
The appearance in England from the 1850s of 'cottage hospitals' in considerable numbers constituted a new and distinctive form of hospital provision. The historiography of hospital care has emphasised the role of the large teaching hospitals, to the neglect of the smaller and general practitioner hospitals. This article inverts that attention, by examining their history and shift in function to 'community hospitals'within their regional setting in the period up to 2000. As the planning of hospitals on a regional basis began from the 1920s, the impact of NHS organisational and planning mechanisms on smaller hospitals is explored through case studies at two levels. The strategy for community hospitals of the Oxford NHS Region--one of the first Regions to formulate such a strategy--and the impact of that strategy on one hospital, Watlington Cottage Hospital, is critically examined through its existence from 1874 to 2000.
Article
Moll van Charante EP, Hartman EE, IJzermans CJ, Voogt E, Klazinga NS, Bindels PJE. De huisartsenkliniek in IJmuiden. Een bijzonder transmuraal experiment. Huisarts Wet 2005;48(3):102-8. Inleiding Bij de sluiting van het voormalige Zeewegziekenhuis te IJmuiden in 1996 ontstond een bijzonder transmuraal experiment: de huisartsenkliniek. Hierin kregen de huisartsen van de RHV IJmond, ondersteund door 24-uurs verpleegkundige zorg, de medische regie over een klinische afdeling met 20 bedden ten behoeve van de behandeling van eigen patiënten, postoperatieve patiënten in het laatste deel van hun revalidatie en specialistisch uitbehandelde patiënten met een verpleeghuisindicatie. Doel van dit onderzoek was met name het type patiënten te beschrijven dat door de huisarts werd opgenomen en de rol te onderzoeken die de huisartsenkliniek zou kunnen spelen in de substitutie van zorg. Methoden Prospectief observationeel onderzoek van alle patiënten die tussen 1 juni 1999 en 1 juni 2000 werden opgenomen met behulp van dossieronderzoek, vragenlijstonderzoek naar de kwaliteit van leven (SF-36) en ADL (GARS), een vragenlijst voor de huisartsen over de ernst van ziekte (Duke Severity of Illness Checklist) en over de keuze voor een andere zorgsetting indien de huisartsenkliniek niet beschikbaar was geweest. Resultaten In totaal werden 218 opnames geregistreerd. Deze werden verdeeld over de genoemde 3 bedcategorieën: huisartsenbedden (n=131), herstelbedden (n=62) en verpleeghuisbedden (n=25). De gemiddelde leeftijd van alle patiënten was 76 jaar. Belangrijkste opname-indicaties waren: immobilisatie na een val (huisartsenbedden), revalidatie van een botbreukoperatie (herstelbedden) en beroerte (verpleeghuisbedden). Zonder huisartsenkliniek waren de patiënten op de huisartsenbedden bijna gelijkelijk verdeeld geweest over de thuis-, verpleeghuis- en ziekenhuiszorg. De ziektescore bij opname was voor de patiënten die anders naar het ziekenhuis waren verwezen significant hoger dan voor de andere twee zorgalternatieven. De kwaliteit van leven was voor alle patiënten bij opname laag tot zeer laag. Conclusie De huisartsenkliniek te IJmuiden lijkt een waardevolle substitutie van zorg te kunnen leveren voor zowel thuis-, verpleeghuis- als ziekenhuiszorg, met name voor oudere patiënten die behoefte hebben aan kortdurende verpleegkundige en medische zorg.
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Proefschrift Universiteit van Amsterdam. Met samenvatting in het Nederlands.
Article
To audit the workload of a general practitioner hospital and to compare the results with an earlier study. Prospective recording of discharges from the general practitioner hospital plus outpatient and casualty attendances and of all outpatient referrals and discharges from other hospitals of patients from Brecon Medical Group Practice during one year (1 June 1986-31 May 1987). A large rural general group practice which staffs a general practitioner hospital in Brecon, mid-Wales. 20,000 Patients living in the Brecon area. 1540 Patients were discharged from the general practitioner hospital during the study period. The hospital accounted for 78% (1242 out of 1594) of all hospital admissions of patients of the practice. There were 5835 new attendances at the casualty department and 1896 new outpatient attendances at consultant clinics at the hospital. Of all new outpatient attendances by patients of the practice, 71% (1358 out of 1896) were at clinics held at the general practitioner hospital. Since the previous study in 1971 discharges from the hospital have increased 37% (from 1125 to 1540) and new attendances at consultant clinics 30% (from 1450 to 1896). The average cost per inpatient day is lower at this hospital than at the local district general hospital (pounds 71.07 v pounds 88.06 respectively). The general practitioner hospital deals with a considerably larger proportion of admissions and outpatient attendances of patients in the practice than in 1971 and eases the burden on the local district general hospital at a reasonable cost. General practitioner hospitals should have a future role in the NHS.
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This study is a survey of general practitioners practising in an area in Melbourne, Australia, where there are two medium sized public hospitals with limited general practitioner admitting rights. A questionnaire was mailed to the 207 general practitioners practising in the study area; 167 (81%) responded. Seventy one per cent of respondents had public hospital admitting rights and 73% aimed to manage as many medical patients in hospital as possible. The main reasons given for such involvement were patient expectation, professional satisfaction and the benefits to patients, beyond that of reassurance, which followed from continuity of care. About half of respondents (52%) agreed that their role was a liaison or coordinating one alongside hospital specialists. Fifty-four per cent of respondents overall had in fact managed at least two medical patients in public hospitals in the past 12 months. Lack of availability of general practitioner beds and specialist dominance in public hospitals rather than inadequate time or remuneration were perceived to be the main barriers to hospital practice. Almost three-quarters of respondents (72%) believed general practitioners would be excluded from public hospitals in the foreseeable future. They blamed specialist dominance and general practitioner apathy equally for this predicted state of affairs. A debate on the desirability or otherwise of such an exclusion is overdue within the medical community in order to consider what will otherwise be a fait accompli.
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Few general practitioners in the United Kingdom do minor surgery, in contrast to their colleagues in other countries. The reasons are largely historical and relate to the structure and function of the National Health Service. This history of minor surgery describes its common occurrence before the NHS, its virtual disappearance after the NHS came about, and later revival by a few enthusiasts. The state of the art describes the wide range of surgical procedures in general surgery, orthopaedics, ear-nose-and-throat, gynaecology and ophthalmology. There are few complications, and very short waiting times in general practice minor surgery. The workload is not great. Economic studies show great saving may be made. Patients strongly prefer general practice minor surgery. In conclusion, despite many advantages, there remain major financial disadvantages for general practitioners in the United Kingdom to provide minor surgery for their patients.
Article
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Discussion over health needs and health care in the U.K. has mainly centered on the urban area. The countryside has not been included in this debate because it is assumed that rural people are healthier than their urban counterparts and that health and social services are more effective. This paper questions these two premises and shows higher than expected levels of illness in the rural area and the health services to be largely dependent on general practice which, like all rural services, is becoming increasingly centralised and inaccessible. What is needed, it is argued, is the construction of a case for more localised care. Not that this should necessarily lead to a singularly rural type of health service, rather that patterns of provision should be adapted to local needs wherever they are situated.
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The cost-effectiveness of operative surgery in small local acute hospitals and in a district general hospital has been compared. In the largest local hospital with a catchment of 116 thousand, the cost-effectiveness is as great as in the district general hospital. The smaller local hospitals were less cost-effective. An option appraisal indicates that when local hospitals are rebuilt, only one operating theatre should be provided to serve the catchment of the two smaller local hospitals.
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The results of a prospective analysis of one year's surgery on inpatients in a busy community hospital showed that a high quality of surgery may be achieved with safety and low rates of complications. The results of a retrospective analysis of certain aspects of surgery was just as encouraging. Surgery that is performed in a community hospital is convenient for the patient, provides continuity of care by the general practitioner, and waiting list times are short. Surgical facilities can form an integral part of the comprehensive service provided by a community hospital and can lighten the caseload for minor surgery at the district general hospital. Close liaison between the two hospitals is essential.
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The first inner city general practitioner community hospital opened on 4 January 1982. This paper describes the operation of the hospital over the first 12 months. There were 316 admissions, with an average length of stay of 13 days. The average age of the patients was 73 and the most common reason for admission was disease of the respiratory system. Thirty five per cent of patients were admitted because of an acute illness and 37% were admitted on the same day as the request for admission. The policies of intermittent or phased care allowed for the admission of patients at regular intervals to relieve carers, and the assessment of the home circumstances of all patients allowed for planning the patient's return home.
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A postal survey of isolated general practitioner maternity units in England and Wales showed that just under 4% of deliveries take place in them. Eight per cent of general practitioners are on the staffs, and in 87% of units midwives are integrated with the community midwifery service. Sixty two per cent of units have visiting consultant cover. Fifty seven per cent of patients are booked and delivered in the unit, 28% are booked and deliberately delivered elsewhere, 5% are transferred in the antenatal period, and 10% transferred as emergencies. The perinatal mortality rate for cases booked and delivered in the units is 1.1 per 1000. The number of emergency transfers was appreciably less for those units that were prepared to do their own operations. Thirty five per cent of these units are liable to be cut off in bad weather, and they will continue to fulfil an essential role in the midwifery services.
Article
The shift in care from secondary to primary services is likely to place greater demands on community hospitals. Before changes in the provision of community hospitals can occur, baseline data are needed, outlining their current use. A study was undertaken to obtain baseline data describing the use of general practitioner beds in Leicestershire community hospitals. A three-month prospective, observational study was carried out between February and May 1992 using data from a questionnaire completed by nurses and general practitioners and from patient hospital records. Study patients comprised all patients admitted to general practitioner beds in all eight Leicestershire community hospitals. A 100% questionnaire response rate was obtained giving data on 685 hospital admissions. Around 70% of admissions were of patients aged 75 years and over. Of admissions, 35% were for acute care, 31% for respite care, 22% for rehabilitation, 7% for terminal/palliative care and 5% for other reasons. Fifteen per cent of patients had been transferred from a consultant bed. Of those not transferred, 91% were admitted by their usual general practitioner or practice partner and for 96% of these patients this was the general practitioner's first choice for care. There was significant variation in both the age mix and care category mix of patients between individual hospitals. Medical deterioration in an underlying condition and family pressure on the general practitioner or carers' inability to cope each contributed to around half of all admissions. Of all admissions, 38% lived alone, and 18% of carers were disabled. Incontinence was reported for 35% of patients, and 26% of all patients were of a high nursing dependency. There was low utilization of community services before admission and 33% received none. There was variation between individual hospitals in use of local and district general hospital investigations, specialist referral and types of therapy. Of 685 admissions 11% died during their stay. Of those discharged, 76% went to their own or a relative's home, 10% to a residential or nursing home and 9% were transferred to an acute bed. Nine percent of discharges were postponed and 10% were brought forward. On discharge to non-residential care, 26% of patients received no community services. Shifting resources from secondary to primary care is a priority for purchasers. Both the introduction of the National Health Service and community care act 1990, and acute units having increasing incentives for earlier discharge, are likely to place greater demands on community hospital beds. Not all general practitioners have the option of community hospital beds. Before access to general practitioner beds can be broadened, existing beds should be used appropriately and shown to be cost-effective. Purchasers therefore require criteria for the appropriateness of admissions to general practitioner beds, and the results of a general practitioner bed cost-benefit analysis.
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All deaths from cancer were identified from death certificates in the Exeter Health District for a period of one year. Place of death, age, cancer type and access to general practitioner community hospital beds and the domiciliary hospice service were recorded. There were 1022 deaths attributable to cancer (parts 1 a, 1 b or 1 c of the death certificate) who were patients of general practitioners in the health district. The place of death for patients with access to community hospital beds were: home 173/590(29%), community hospital 232/590 (39%), specialist services unit 102/590 (17%), nursing or residential home 32/590 (5%), Marie Curie hospice 51/590 (9%). For patients without access to community hospital beds the place of death was: home 177/427 (41 %), specialist services unit 165/427 (39%), nursing or residential home 42/427 (10%), Marie Curie hospice 43/427 (10%). The presence of community hospital beds was associated with a significant reduction of deaths in the specialist service unit ( p<0.001) and with a smaller reduction in home deaths ( p<0.01). Access to the domiciliary hospice services in areas with community beds was not associated with any significant change in the place of death. General practitioners cared for 74% of cases at the time of death in areas with access to community hospital beds and for 51 % of cases without such access, which was a significant difference ( p <0.001). It therefore appears that community hospitals play a major role in the terminal care of cancer patients and access to such beds is associated with a decrease in cancer deaths occurring in specialist services beds.
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Community hospitals have been supported by the general public and by professionals as one means of increasing choice between local, low technology, care and high technology care at the district general hospital. However, there is no information on the impact of community hospitals on district general hospital use subsequent to NHS and community care reforms. Examination of routinely gathered activity data in the Bath Health District revealed that availability of community hospital beds was associated with reduced use of central inpatient services in the city of Bath. The reduction was most apparent for medical and geriatric beds. Decrease in the use of surgical beds was small. However, total inpatient bed use (including central and community hospital beds) was higher in the population with access to community hospital beds. We conclude that community hospitals offer one option for accessible health care and, as such, merit systematic evaluation of costs and benefits. This study presents some evidence that savings could be achieved through improved efficiency.
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