HEALTH SERVICES AND DELIVERY RESEARCH

HEALTH SERVICES AND DELIVERY RESEARCH VOLUME 5 ISSUE 19 JUNE 2017 ISSN 2050-4349 Community hospitas and their services in the NHS: identifying transferabe earning from internationa deveopments scoping review, systematic review, country reports and case studies Emma Pitchforth, Een Note, Jennie Corbett, Céine Miani, Eeanor Winpenny, Edwin van Teijingen, Natasha Emore, Sarah King, Sarah Ba, Joanna Mier and Tom Ling DOI 10.3310/hsdr05190

Community hospitas and their services in the NHS: identifying transferabe earning from internationa deveopments scoping review, systematic review, country reports and case studies Emma Pitchforth, 1 * Een Note, 2 Jennie Corbett, 1 Céine Miani, 1 Eeanor Winpenny, 1 Edwin van Teijingen, 4 Natasha Emore, 5 Sarah King, 6 Sarah Ba, 1 Joanna Mier 1,7 and Tom Ling 1 1 Cambridge Centre for Heath Services Research (CCHSR), RAND Europe, Cambridge, UK 2 European Observatory on Heath Systems and Poicies, London Schoo of Economics and Poitica Science and London Schoo of Hygiene & Tropica Medicine, London, UK 3 Medica Research Counci (MRC) Epidemioogy Unit and Centre for Diet and Activity Research, University of Cambridge, Cambridge, UK 4 Department of Human Sciences and Pubic Heath, University of Bournemouth, Bournemouth, UK 5 Cambridge Centre for Heath Services Research (CCHSR), Institute of Pubic Heath, University of Cambridge, Cambridge, UK 6 RAND Europe, Cambridge, UK 7 Institute of Heath and Webeing, University of Gasgow, Gasgow, UK *Corresponding author Decared competing interests of authors: Edwin van Teijingen decares membership of the HTA Cinica Trias Board. Pubished June 2017 DOI: 10.3310/hsdr05190 This report shoud be referenced as foows: Pitchforth E, Note E, Corbett J, Miani C, Winpenny E, van Teijingen E, et a. Community hospitas and their services in the NHS: identifying transferabe earning from internationa deveopments scoping review, systematic review, country reports and case studies. Heath Serv Deiv Res 2017;5(19).

Heath Services and Deivery Research ISSN 2050-4349 (Print) ISSN 2050-4357 (Onine) This journa is a member of and subscribes to the principes of the Committee on Pubication Ethics (COPE) (www.pubicationethics.org/). Editoria contact: journas.ibrary@nihr.ac.uk The fu HS&DR archive is freey avaiabe to view onine at www.journasibrary.nihr.ac.uk/hsdr. Print-on-demand copies can be purchased from the report pages of the NIHR Journas Library website: www.journasibrary.nihr.ac.uk Criteria for incusion in the Heath Services and Deivery Research journa Reports are pubished in Heath Services and Deivery Research (HS&DR) if (1) they have resuted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficienty high scientific quaity as assessed by the reviewers and editors. HS&DR programme The Heath Services and Deivery Research (HS&DR) programme, part of the Nationa Institute for Heath Research (NIHR), was estabished to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Heath Services Research (HSR) programme and the Service Deivery and Organisation (SDO) programme, which were merged in January 2012. The HS&DR programme aims to produce rigorous and reevant evidence on the quaity, access and organisation of heath services incuding costs and outcomes, as we as research on impementation. The programme wi enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evauative research to improve heath services. For more information about the HS&DR programme pease visit the website: http://www.nets.nihr.ac.uk/programmes/hsdr This report The research reported in this issue of the journa was funded by the HS&DR programme or one of its preceding programmes as project number 12/177/14. The contractua start date was in March 2014. The fina report began editoria review in Apri 2016 and was accepted for pubication in October 2016. The authors have been whoy responsibe for a data coection, anaysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors report and woud ike to thank the reviewers for their constructive comments on the fina report document. However, they do not accept iabiity for damages or osses arising from materia pubished in this report. This report presents independent research funded by the Nationa Institute for Heath Research (NIHR). The views and opinions expressed by authors in this pubication are those of the authors and do not necessariy refect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. If there are verbatim quotations incuded in this pubication the views and opinions expressed by the interviewees are those of the interviewees and do not necessariy refect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. Queen s Printer and Controer of HMSO 2017. This work was produced by Pitchforth et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Pubished by the NIHR Journas Library (www.journasibrary.nihr.ac.uk), produced by Prepress Projects Ltd, Perth, Scotand (www.prepress-projects.co.uk).

Heath Services and Deivery Research Editor-in-Chief Professor Jo Rycroft-Maone Professor of Heath Services and Impementation Research, Bangor University, UK NIHR Journas Library Editor-in-Chief Professor Tom Waey Director, NIHR Evauation, Trias and Studies and Director of the EME Programme, UK NIHR Journas Library Editors Professor Ken Stein Chair of HTA Editoria Board and Professor of Pubic Heath, University of Exeter Medica Schoo, UK Professor Andree Le May Chair of NIHR Journas Library Editoria Group (EME, HS&DR, PGfAR, PHR journas) Dr Martin Ashton-Key Consutant in Pubic Heath Medicine/Consutant Advisor, NETSCC, UK Professor Matthias Beck Chair in Pubic Sector Management and Subject Leader (Management Group), Queen s University Management Schoo, Queen s University Befast, UK Dr Tessa Criy Director, Crysta Bue Consuting Ltd, UK Dr Eugenia Cronin Senior Scientific Advisor, Wessex Institute, UK Ms Tara Lamont Scientific Advisor, NETSCC, UK Dr Catriona McDaid Senior Research Feow, York Trias Unit, Department of Heath Sciences, University of York, UK Professor Wiiam McGuire Professor of Chid Heath, Hu York Medica Schoo, University of York, UK Professor Geoffrey Meads Professor of Heath Sciences Research, Heath and Webeing Research Group, University of Winchester, UK Professor John Norrie Chair in Medica Statistics, University of Edinburgh, UK Professor John Powe Consutant Cinica Adviser, Nationa Institute for Heath and Care Exceence (NICE), UK Professor James Raftery Professor of Heath Technoogy Assessment, Wessex Institute, Facuty of Medicine, University of Southampton, UK Dr Rob Riemsma Reviews Manager, Keijnen Systematic Reviews Ltd, UK Professor Heen Roberts Professor of Chid Heath Research, UCL Institute of Chid Heath, UK Professor Jonathan Ross Professor of Sexua Heath and HIV, University Hospita Birmingham, UK Professor Heen Snooks Professor of Heath Services Research, Institute of Life Science, Coege of Medicine, Swansea University, UK Professor Jim Thornton Professor of Obstetrics and Gynaecoogy, Facuty of Medicine and Heath Sciences, University of Nottingham, UK Professor Martin Underwood Director, Warwick Cinica Trias Unit, Warwick Medica Schoo, University of Warwick, UK Pease visit the website for a ist of members of the NIHR Journas Library Board: www.journasibrary.nihr.ac.uk/about/editors Editoria contact: journas.ibrary@nihr.ac.uk NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr05190 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 19 Abstract Community hospitas and their services in the NHS: identifying transferabe earning from internationa deveopments scoping review, systematic review, country reports and case studies Emma Pitchforth, 1 * Een Note, 2 Jennie Corbett, 1 Céine Miani, 1 Eeanor Winpenny, 1 Edwin van Teijingen, 4 Natasha Emore, 5 Sarah King, 6 Sarah Ba, 1 Joanna Mier 1,7 and Tom Ling 1 1 Cambridge Centre for Heath Services Research (CCHSR), RAND Europe, Cambridge, UK 2 European Observatory on Heath Systems and Poicies, London Schoo of Economics and Poitica Science and London Schoo of Hygiene & Tropica Medicine, London, UK 3 Medica Research Counci (MRC) Epidemioogy Unit and Centre for Diet and Activity Research, University of Cambridge, Cambridge, UK 4 Department of Human Sciences and Pubic Heath, University of Bournemouth, Bournemouth, UK 5 Cambridge Centre for Heath Services Research (CCHSR), Institute of Pubic Heath, University of Cambridge, Cambridge, UK 6 RAND Europe, Cambridge, UK 7 Institute of Heath and Webeing, University of Gasgow, Gasgow, UK *Corresponding author epitchfo@rand.org Background: The notion of a community hospita in Engand is evoving from the traditiona mode of a oca hospita staffed by genera practitioners and nurses and serving mainy rura popuations. Aong with the diversification of modes, there is a renewed poicy interest in community hospitas and their potentia to deiver integrated care. However, there is a need to better understand the roe of different modes of community hospitas within the wider heath economy and an opportunity to earn from experiences of other countries to inform this potentia. Objectives: This study sought to (1) define the nature and scope of service provision modes that fit under the umbrea term community hospita in the UK and other high-income countries, (2) anayse evidence of their effectiveness and efficiency, (3) expore the wider roe and impact of community engagement in community hospitas, (4) understand how modes in other countries operate and asses their roe within the wider heath-care system, and (5) identify the potentia for community hospitas to perform an integrative roe in the deivery of heath and socia care. Methods: A mutimethod study incuding a scoping review of community hospita modes, a inked systematic review of their effectiveness and efficiency, an anaysis of experiences in Austraia, Finand, Itay, Norway and Scotand, and case studies of four community hospitas in Finand, Itay and Scotand. Resuts: The evidence reviews found that community hospitas provide a diverse range of services, spanning primary, secondary and ong-term care in geographica and heath system contexts. They can offer an effective and efficient aternative to acute hospitas. Patient experience was frequenty reported to be better at community hospitas, and the cost-effectiveness of some modes was found to be simiar to that of genera hospitas, athough evidence was imited. Evidence from other countries showed that Queen s Printer and Controer of HMSO 2017. This work was produced by Pitchforth et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. v

ABSTRACT community hospitas provide a wide spectrum of heath services that ie on a continuum between serving a geographic purpose and having a specific popuation focus, mainy oder peope. Structures continue to evove as countries embark on major reforms to integrate heath and socia care. Case studies highighted that it is important to consider oca and nationa contexts when ooking at how to transfer modes across settings, how to overcome barriers to integration beyond ocation and how the community shoud be best represented. Limitations: The use of a restricted definition may have excuded some reevant community hospita modes, and the sma number of countries and case studies incuded for comparison may imit the transferabiity of findings for Engand. Athough this research provides detaied insights into community hospitas in five countries, it was not in its scope to incude the perspective of patients in any depth. Concusions: At a time when emphasis is being paced on integrated and community-based care, community hospitas have the potentia to assume a more strategic roe in heath-care deivery ocay, providing care coser to peope s homes. There is a need for more research into the effectiveness and cost-effectiveness of community hospitas, the roe of the community and optima staff profie(s). Funding: The Nationa Institute for Heath Research Heath Services and Deivery Research programme. vi NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr05190 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 19 Contents List of tabes List of figures List of boxes List of abbreviations Pain Engish summary Scientific summary xi xiii xv xvii xix xxi Chapter 1 Introduction 1 Background 1 Aims and objectives 2 Structure of the report 2 Patient and pubic invovement 3 Proposa stage 3 During the project 3 Steering group and co-ordination with reated studies 4 Ethics approva and research governance 4 Part 1 Literature reviews and evidence synthesis 5 Chapter 2 Community hospitas in seected high-income countries: a scoping review of approaches and modes 7 Introduction 7 Methods 7 Findings 9 Range of services provided by community hospitas 10 Staffing of community hospitas 13 Coaboration and integration with other services 14 Ownership of community hospitas 15 Discussion 16 Limitations of the review 17 Concusion 18 Chapter 3 Community hospitas in high-income countries: a systematic review of the evidence on effectiveness and cost-effectiveness 19 Introduction 19 Methods 19 Findings 21 Patient heath outcomes 24 Patient and carer experience and satisfaction 24 Staff experience and organisationa effectiveness 25 Cost and cost-effectiveness 26 Discussion 27 Queen s Printer and Controer of HMSO 2017. This work was produced by Pitchforth et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. vii

CONTENTS Part 2 Internationa review and comparison 29 Chapter 4 Understanding the roe of community hospitas within the wider system of service provision: a comparative anaysis of experiences in five countries 31 Introduction 31 Methods 31 Country seection 32 Data coection 32 Findings 34 Principa features of heath system governance, finance and organisation 34 Organisation and funding of hospita services 34 Community hospitas in five countries: types and services provided 38 Benefits of community hospitas 42 Chaenges faced by community hospitas 43 Future changes in community hospita provision 45 Discussion 47 Chapter 5 Innovative modes of community hospitas in Scotand: a mutipe case study 49 Introduction 49 Methods 49 Study design 49 Samping 50 Data coection 50 Anaysis 51 Findings 51 Key roes and functions of community hospitas 51 Factors affecting the functioning of community hospitas 56 Discussion 60 Concusion 61 Chapter 6 Comparing community hospitas in Europe: a cross-case anaysis of modes in Finand, Itay and Scotand 63 Introduction 63 Methods 63 Case-study seection 63 Case-study methodoogy 64 Case-study country settings 65 Findings 66 Community hospitas evoving within heath systems settings 66 Function and environment 70 Integration versus co-ocation 70 Staffing and management 71 The roe of the community 72 Discussion 73 Concusion 74 Chapter 7 Concusions and recommendations 77 Evidence synthesis: roes and features, and evidence of effectiveness and cost-effectiveness of community hospitas 77 Learning from internationa experience 78 Experiences of community hospitas in five countries 78 Case studies of innovative modes of community hospitas in three countries 78 viii NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr05190 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 19 Limitations of this study 79 Research recommendations 80 Acknowedgements 81 References 83 Appendix 1 Patient and pubic invovement: roe description 105 Appendix 2 Quaity assessment tabes for the systematic review of the evidence on effectiveness and cost-effectiveness 107 Appendix 3 Country report data coection tempate 119 Appendix 4 Country report interview protoco 121 Appendix 5 Internationa experiences: individua country reports 125 Appendix 6 Key features of service provision and payment in primary and ambuatory care in five countries 185 Appendix 7 Case studies in Scotand: interview topic guide 187 Appendix 8 Internationa experiences: individua case studies 191 Queen s Printer and Controer of HMSO 2017. This work was produced by Pitchforth et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. ix

DOI: 10.3310/hsdr05190 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 19 List of tabes TABLE 1 Definitions of community hospitas 8 TABLE 2 Incusion and excusion criteria 10 TABLE 3 Overview of services provided by community hospitas in different countries 12 TABLE 4 Incusion and excusion criteria 20 TABLE 5 Overview of incuded studies (isted by study and type) 22 TABLE 6 Stakehoders represented by interviews in each country 34 TABLE 7 Heath system financing and governance in five countries, 2013 35 TABLE 8 Key features of hospita provision and payment in five countries 36 TABLE 9 Principa features of community hospitas in five countries 39 TABLE 10 Stakehoder interview participants by case and stakehoder group 52 TABLE 11 Case descriptions 52 TABLE 12 Data coection methods used in case study 64 TABLE 13 Summary case description (Cases A D) 67 TABLE 14 Stakehoder interviewees by case and stakehoder group 69 TABLE 15 Quaity assessment: papers reporting on quaitative studies 108 TABLE 16 Quaity assessment: papers reporting on RCTs 109 TABLE 17 Quaity assessment: papers reporting on cost (effectiveness) anayses, checkist based on Drummond et a. 114 TABLE 18 Quaity assessment: papers reporting on quantitative observationa (cohort) studies 114 TABLE 19 Pubic hospita categories in Austraia, 2013 14 137 TABLE 20 Loca medica centres 172 TABLE 21 Hospita cassification 183 TABLE 22 Key features of service provision and payment in primary care 185 TABLE 23 Stakehoder interviewees by officia tite 192 TABLE 24 Age range of popuation, December 2013 193 Queen s Printer and Controer of HMSO 2017. This work was produced by Pitchforth et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xi

LIST OF TABLES TABLE 25 Overview of heath centre services 194 TABLE 26 Overview of sateite heath cinics 196 TABLE 27 Structure staffing in the heath centre hospita 197 TABLE 28 Description of the regiona hospita 197 TABLE 29 Detais of interviews carried out 208 TABLE 30 Differences to the case-study service mode before and after May 2015 211 TABLE 31 Demographics (2014) 212 TABLE 32 Hospita activity indices, 2014 213 TABLE 33 Community hospita admissions by diagnosis, 2014 214 TABLE 34 Distances to oca acute and emergency care services 215 xii NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr05190 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 19 List of figures FIGURE 1 Studies eigibe for incusion 11 FIGURE 2 Nature and scope of services provided by community hospitas 16 FIGURE 3 Literature incuded in the study 21 FIGURE 4 Heath-care expenditure by function as percentage of tota recurrent heath expenditure, Austraia, 2013 14 126 FIGURE 5 Heath-care expenditure (recurrent) by sector and funding source, in AU$M, Austraia, 2013 14 127 FIGURE 6 Tota number of hospitas and hospitas per miion popuation in Austraia, 1997 2012 129 FIGURE 7 Hospita beds per thousand popuation in Austraia, 1995 2012 129 FIGURE 8 Pubic acute and psychiatric hospitas, by hospita size, Austraian states and territories, 2013 14 131 FIGURE 9 Heath-care expenditure by function as percentage of tota heath expenditure, Finand, 2013 140 FIGURE 10 Tota number of hospitas and hospitas per miion popuation Finand, 1995 2013 (a hospitas) 142 FIGURE 11 Hospita beds per thousand popuation in Finand, 2000 13 142 FIGURE 12 Long-term inpatients in heath centres (as a proportion of the popuation in the reevant age group), 2000 14 145 FIGURE 13 Aocation of resources to the basic benefit package (LEA) items (percentage of nationa heath fund), Itay, 2011 151 FIGURE 14 Tota number of hospitas and hospitas per miion popuation in Itay, 1990 2012 154 FIGURE 15 Hospita beds per thousand popuation in Itay, 1990 2012 154 FIGURE 16 Heath-care expenditure by function as percentage of tota heath expenditure, Norway, 2014 164 FIGURE 17 Hospita beds per 1000 popuation in Norway, 2002 14 166 FIGURE 18 Operating costs (in B) in NHS Scotand, by sector in NHS Scotand, 2012 13 175 FIGURE 19 Hospitas in Scotand, by major category (absoute number), 2015 176 Queen s Printer and Controer of HMSO 2017. This work was produced by Pitchforth et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xiii

LIST OF FIGURES FIGURE 20 Hospitas in Scotand by category and size (average staffed beds), 2015 177 FIGURE 21 Numbers of hospita beds, by hospita type (2010 13) 177 FIGURE 22 Historica timeine 210 xiv NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr05190 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 19 List of boxes BOX 1 PubMed search strategy 9 BOX 2 Incusion criteria for case-study seection 50 BOX 3 Cairns and Hinterand Hospita and Heath Service, Queensand 133 BOX 4 Katherine District Hospita, Northern Territory 134 BOX 5 The Northern Satakunta basic-service pubic-utiity federation of municipaities 147 BOX 6 Socia care in Itay 153 BOX 7 Defining the community hospita in Itay: nationa framework 157 BOX 8 Cottage hospitas in Finnmark county 168 BOX 9 Trondheim teaching nursing home 168 BOX 10 Loca medica centre in Stjørda 170 BOX 11 Working definition of community hospitas 179 BOX 12 Socia and heath services provided under the co-operation area 179 BOX 13 Heath services avaiabe in the house of heath (incuding the community hospita) 213 Queen s Printer and Controer of HMSO 2017. This work was produced by Pitchforth et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xv

DOI: 10.3310/hsdr05190 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 19 List of abbreviations A&E accident and emergency MBS Medicare Benefits Scheme ADL activities of daiy iving MOSS Medica Officer of Specia Scae ASL Aziende Sanitarie Locai MPS Mutipurpose Service CHP CI CINAHL COPD community heath partnership confidence interva Cumuative Index to Nursing and Aied Heath Literature chronic obstructive pumonary disease NETSCC NHI NIHR NOK NIHR Evauation, Trias and Studies Coordinating Centre Nationa Heath Insurance Nationa Institute for Heath Research Norwegian kroner DRG FTE GDP GP HADS diagnosis-reated group fu-time equivaent gross domestic product genera practitioner Hospita Anxiety and Depression Scae OECD OR PBS PFI PHN Organisation for Economic Co-operation and Deveopment odds ratio Pharmaceutica Benefits Scheme private finance initiative Primary Heath Network HELFO HMIC IHPA Norwegian Heath Economics Administration Heath Management Information Consortium Independent Hospita Pricing Authority PIP PPI PPP QALY RCT Practice Incentive Program patient and pubic invovement purchasing power parity quaity-adjusted ife-year randomised controed tria IRCCS ISD IT KAD Istituti di ricovero e cura a carattere scientifico Information Services Division information technoogy kommunae akutte døgnpasser RHA RSA SD SIRCO regiona heath authority Residenza Sanitaria Assistenziae standard deviation Regiona Community Hospitas Information System LEA Livei Essenziai di Assistenza SSN Servizio Sanitario Nazionae LHN oca hospita network UCCP Unità Compesse di Cure Primarie Queen s Printer and Controer of HMSO 2017. This work was produced by Pitchforth et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xvii

DOI: 10.3310/hsdr05190 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 19 Pain Engish summary Community hospitas in Engand have usuay been oca hospitas in which genera practitioners and nurses provide care, often for rura popuations who traditionay have difficuties in accessing arger genera hospitas, which tend to be set in more urban areas. Because of a gobay ageing popuation and advances in heath service organisation and technoogies, different types of community hospitas have now deveoped. It is important to better understand these modes, how they work and how they might be used in the Engish NHS in the future. The experiences of community hospitas in other countries may provide important insights and, therefore, we reviewed existing research and carried out detaied studies of five countries (Austraia, Finand, Itay, Norway and Scotand), which incuded interviews with experts in each. We aso visited four individua community hospitas in Finand, Itay and Scotand, interviewed staff, observed daiy activities and anaysed documents. Our findings show that community hospitas provide a wide range of services. They can bring together different parts of heath, socia and community care, but the way in which this is done within and across different countries varies. Community hospitas can provide effective care and are vaued by patients and their famiies, but there is imited evidence to understand these benefits against the costs of community hospitas. Community hospitas coud make an important contribution as the NHS deveops new ways of working, but there are a number of chaenges, incuding how they shoud be staffed, the degree of oca contro and how communities can best be invoved. Queen s Printer and Controer of HMSO 2017. This work was produced by Pitchforth et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xix

DOI: 10.3310/hsdr05190 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 19 Scientific summary Background Traditionay, community hospitas have been defined as oca hospitas that are typicay staffed mainy by genera practitioners (GPs) and nurses to provide care in a hospita setting, often for predominanty rura popuations. However, the notion of a community hospita has evoved over time, with a diversity of service deivery modes deveoping in response to the needs of the oca popuations served and in the context of a broader change in the nature of the deivery of heath-care services themseves. In Engand, a growing poicy focus on care integration and on shifting services coser to peope s homes has ed to renewed interest in community hospitas and their potentia roe in deivering more integrated care ocay. There is therefore a need to understand better the roe of different modes of community hospita provision within the wider heath economy and an opportunity to earn from the experiences of other countries in order to inform the future deveopment of community hospitas in Engand. Objectives In order to understand better the roe of different modes of community hospita provision within the wider heath economy and their capacity and capabiity to integrate services ocay, we sought to answer five principa research questions: 1. What is the nature and scope of service provision modes that can be considered under the umbrea term community hospita in Engand and other high-income countries? 2. What is the evidence of their effectiveness and efficiency? 3. What is the wider roe and impact of community engagement in community hospita service deveopment and provision? 4. How do modes that are comparabe to community hospitas in Engand operate and what is their roe within the wider system of service provision? 5. What is the potentia for modes that are comparabe to community hospitas in Engand to perform an integrative roe in the deivery of heath and socia care? Methods We designed a mutimethod study that incuded (1) a scoping review of the academic and grey iterature on current provision of community hospita services in Engand and other high-income countries, (2) a inked systematic review of the effectiveness and cost-effectiveness of community hospitas in Engand and other high-income countries, (3) a review of the nature, scope and distribution of service deivery modes that can be considered to be community hospitas in five high-income countries (Austraia, Finand, Itay, Norway and Scotand), using a review of the pubished and grey iterature foowing a structured data coection tempate and key informant interviews, and (4) four in-depth case studies of the specific financia, organisationa and governance features of community hospita modes in Finand, Itay and Scotand. Findings Seventy-five papers were incuded in the scoping review, the majority of which were descriptive or used a quaitative design. Eeven reported on a randomised controed tria (RCT). Drawing on the same search strategy, 17 papers were incuded in the systematic review of effectiveness and cost-effectiveness of Queen s Printer and Controer of HMSO 2017. This work was produced by Pitchforth et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxi

SCIENTIFIC SUMMARY community hospitas. These covered eight studies from two countries and incuded RCTs (n = 7), quaitative research embedded within a RCT (n = 2), standaone quaitative research (n = 4), an observationa (cohort) study (n = 1) and cost-effectiveness anayses (n = 3). Twenty-eight key informants participated in interviews as part of the country reviews, representing primariy nationa, regiona or oca government, provider or provider associations and academia. The four case studies invoved site visits of between 4 and 10 days and a tota of 45 interviews with managers, cinicians and frontine staff, broader system actors and representatives of the community. Interviews were suppemented with non-participant observation and document review. The roes and features of community hospitas and evidence of effectiveness and efficiency Evidence from the scoping review found that community hospitas provide a wide range of services, covering the entire spectrum of care provision, from preventative and primary care, through to inpatient and outpatient medica and surgica care. There was wide diversity of provision, which appeared to refect oca need. Community hospitas are staffed by a mixture of GPs, generaist and speciaist nurses, aied heath professionas and heath-care assistants, and most community hospitas identified in the review were pubic hospitas under the responsibiity of government heath authorities. There were many exampes of coaborative working arrangements between community hospitas and other provider organisations, resuting from the co-ocation of different services at a singe physica ocation, the shared workforce with primary care and cose coaboration with acute care speciaists. Severa studies reported the use of teemedicine to faciitate coaboration between community hospita staff and speciaists. The evidence synthesis highighted that coaborative working at community hospitas may be particuary important in informing the design of future modes of care, whereby emphasis is paced on continuity of care and coaboration between different care sectors. We propose a way to conceptuaise and represent community hospitas, which recognises the diversity of services offered. Evidence of the effectiveness and efficiency of community hospitas was avaiabe from Engand and Norway ony. Studies reported improved or equivaent patient heath outcomes at community hospitas compared with acute hospitas for the post-acute care of oder patients. This incuded increased independence, reduced hospita readmissions and equivaent patient heath outcomes after chemotherapy. Patient and carer experiences were better at community hospitas than at acute hospitas for paiative care, post-acute care and chemotherapy. Across studies, staff were reported to vaue key aspects of the community hospita setting, incuding ease of access and a sense of homeiness, with an improvement in the discharge process from acute to primary care reported in one setting. Cost (effectiveness) resuts were mixed. The cost of post-acute care was either simiar or ower in community hospitas than in acute hospitas. Drug and intervention costs for emergency care were reported to be ower at one community hospita than at the acute hospita, resuting in ower overa costs. However, the cost of deivering chemotherapy in community hospitas was marginay higher than in a cancer centre. Overa, athough evidence of effectiveness of community hospita remains imited in terms of geographica scope and is primariy focused on post-acute care, our findings suggest that community hospitas can offer an effective and efficient aternative to acute hospitas. Experiences of community hospitas in five countries This review of the nature, scope and distribution of community hospitas in Austraia, Finand, Itay, Norway and Scotand found that the term community hospita is not easiy transferabe across system settings. In ine with the scoping review, the country review showed that community hospitas and reated structures provide a wide spectrum of heath services, which can be further conceptuaised as a continuum between community hospitas serving a geographic purpose, typicay rura popuations, at one end, and having a specific popuation focus, mainy oder and frai peope, at the other end of the care spectrum. xxii NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr05190 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 19 However, boundaries may be burred when the oca community constitutes a specific group, such as indigenous popuations. Overa, the community hospita as such represents a fuid concept, with the greatest advantage perhaps being their fexibiity to respond to oca need. The evidence presented here underines the potentia for community hospitas to occupy a niche within the oca service deivery structure. This niche may stretch from viewing community hospitas as a ocae for service integration ocay, as in Scotand, to their function as a component of ocay integrated heath and care services, such as in Finand, Itay and the newy estabished oca (community) heath centres in Norway. Community hospitas face a number of chaenges, such as attracting suitabe staff and maintaining a diverse ski set. There was aso a perception that, as deivery systems are evoving, boundaries between services provided by community hospitas and those offered esewhere ocay might bur or indeed overap, impacting on the effectiveness and efficiency of service deivery and potentiay undermining the vaue of the community hospita and simiar structures. Case studies of innovative modes of community hospitas in three countries The cross-case anaysis of innovative community hospita modes in three countries shows that, athough modes have evoved differenty, they commony provide a range of heath and socia care services in a ess medicaised environment than in acute hospitas and serve as a potentia bridge between primary and secondary care. Common features incude the breadth of services provided within an overarching ethos and to predominanty oder popuations. It was aso evident that a community hospitas paced priority on preventative services and home-based rather than hospita care. There was scope in a four modes for community hospitas to be fexibe in how they deveoped services, but there was aso evidence that this coud be imited by a number of factors, from the constraints of physica space to organisationa changes and pressures in the wider heath-care system. It was cear from the different cases that community hospitas have great potentia for integrating services that traditionay may have been separated. Creating a pace for co-ocation of these services was seen to promote mutidiscipinary working, but a number of chaenges remained. The abiity to effectivey share patient information was hampered by the incompatibiity of information technoogy (IT) systems. The importance of maintaining one s professiona identity and traditiona boundaries aso prevaied to a greater or esser extent. Athough a sense of ocaness was vaued in a the modes, the extent to which communities were invoved and engaged varied consideraby, ranging from no invovement beyond care transactions to the co-design and the creation of pubic spaces. Finay, staffing requirements often created opportunities and chaenges for hospitas. Working within community hospitas was considered to provide a ayer of chaenge on top of typica roes in primary care, making staff recruitment and retention difficut in some cases. Limitations For the purposes of this study, we defined a community hospita as a service mode that (1) provides a range of services to a oca community, (2) is ed by community-based heath professionas and (3) provides inpatient beds. This definition was informed by a review of existing definitions of community hospitas and consutation with members of the steering group for this project. By using this somewhat restricted definition, in particuar the requirement that the mode has inpatient beds, our evidence reviews may have excuded some service modes that might have usefuy informed the work presented here. However, the definition heped to identify service deivery modes in other countries that coud be considered comparabe to the community hospita mode in the UK. It is important to note that even within Engand, there is no singe definition that captures the wide range of service deivery modes that are presenty considered under the umbrea term of a community hospita. Indeed, our findings emphasise that the notion of a singe, overarching definition for community hospitas may be miseading, given that the concept and range of services is so inherenty diverse. Queen s Printer and Controer of HMSO 2017. This work was produced by Pitchforth et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxiii

SCIENTIFIC SUMMARY In this study we were abe to draw on ony a sma number of countries to expore the diversity of community hospitas in system settings other than Engand, and on even fewer for a detaied anaysis of individua community hospita modes. Ceary, it remains chaenging to derive essons from other systems contexts, given different poicy contexts. At the same time, however, it is important to recognise that heath systems are facing simiar chaenges and that there is considerabe potentia to earn from approaches impemented esewhere to inform domestic poicy choices. Finay, our research aso set out to investigate the wider roe(s) and impact of community engagement in community hospita service deveopment and provision. We were unabe, as part of the evidence reviews, to identify robust pubished evidence that assessed this aspect in a systematic way. Important issues reating to community engagement were brought out in the case studies but did not emerge as a key area of focus in the country review. Concusion and research recommendations This study shows that the concept of a community hospita encompasses a range of service deivery modes that defy the formuation of a singe, overarching definition. This refects the evoution of the nature and scope of services deivered by community hospitas over time in response to changing popuation needs, as we as the broader changes in the nature of the deivery of heath-care services themseves. Evidence on the range of services provided in community hospitas and, in some contexts, their potentiay integrative roe, suggest that a more strategic roe for community hospitas may be timey within NHS Engand. Better definition of their specific roe in service deivery may enabe community hospitas to take on proactive, preventative and step-up functions, away from their frequenty reactive roe in responding to demands esewhere in the system; however, this woud need to be tested. It wi be important, within any process, to recognise oca and nationa contexts that have driven the way that community hospitas have deveoped. Athough promising, we identified a number of important chaenges that community hospitas are facing. These incude the need to deveop sustainabe modes of staffing, particuary in rura areas, and to overcome persisting barriers to integrated care, incuding inadequate IT systems, even where services are co-ocated. Athough thought to be important, further consideration needs to be given to the roe of the community within community hospitas, in particuar whether or not, and how, community hospitas can systematicay identify and respond to oca needs. Informed by these observations, we recommend that future research shoud: 1. assess the effectiveness, efficiency and cost-effectiveness of community hospitas beyond post-acute care 2. evauate the evidence of how community hospitas can and do contribute to new modes of care that are currenty being deveoped within the NHS in Engand 3. expore means of ensuring that community hospitas are configured on the basis of an assessment of oca need and modes of community engagement 4. consider optima staffing profies and training needs of heath professionas in community hospitas 5. anayse the extent to which characteristics of community hospitas identified in this study refect a unique combination of geographica ocation and specifics of the community hospita in a given setting, which was argey, athough not excusivey, rura, and whether these can be transferred to more urban settings. Funding Funding for this study was provided by the Heath Services and Deivery Research programme of the Nationa Institute for Heath Research. xxiv NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr05190 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 19 Chapter 1 Introduction Background Community hospitas form an estabished component of heath-care provision. 1 Historicay, in the UK, community hospitas have been defined as oca hospitas that are typicay staffed mainy by genera practitioners (GPs) and nurses to provide care in a hospita setting, often for predominanty rura popuations. 2 However, the notion of a community hospita has evoved over time, with a wider range of service deivery arrangements and modes deveoping across Engand and the UK more widey. These incude services that support the rehabiitation and recovery of patients, aowing them to resume independent iving more quicky, 3 and community care homes or service modes that do not incude inpatient beds but that provide speciaist care aongside primary care and outreach services. 4 Thus, community hospitas exist in a variety of forms, differing in the nature and scope of services provided, the modes of ownership and management, and the eve of integration with other services. This diversity of service deivery modes refects the needs of the oca popuations served, as we as broader changes in the nature of the deivery of heath-care services. 5 For exampe, advances in medica technoogy have made it possibe to provide many services coser to the patient, with interventions that woud previousy have required a hospita environment now carried out in ambuatory settings. 6 With concerns about the perceived high costs of hospita care, there is increasing interest in moving care into the community in order to increase accessibiity, in particuar in dispersed popuations, and so enhance the responsiveness of the system, and, potentiay, to reduce costs. Avaiabe evidence suggests that community hospitas may offer advantages over arger hospitas for some patients. For exampe, studies examining the impact of rehabiitation care for oder peope found that the community hospita setting was associated with greater independence at 6 months than the district genera hospita setting. 7 11 Other work has pointed to the potentia roe of community hospitas in providing paiative care. 12 It is reported that community hospitas are perceived as friendy and service-user centred; for exampe, evidence from the 2011 Scottish Inpatient Patient Experience Survey found that community hospitas scored above the nationa average on many questions concerning patient experience, 13 and it has been suggested that community hospitas offer a better experience of care than acute hospitas by aowing more integration with patients famiies and home ife. Others have pointed to a strong tradition of community hospitas providing more integrated care. 14 This core feature of the traditiona community hospita assumes a renewed importance given the rising burden of chronic disease, creating a compex set of heath and socia care needs, in particuar among those with mutipe chronic conditions, aongside fraity at od age. Meeting those needs requires the deveopment of deivery systems that bring together a range of professionas and skis from both the cure (heath-care) and care (ong-term and socia care) sectors. 15 Faiure to better integrate or co-ordinate services aong the care continuum may resut in suboptima outcomes, such as potentiay preventabe hospitaisation, medication errors or adverse drug events. 16 A recent commitment by nationa partners to support service integration emphasised the use of existing structures to aign the NHS, pubic heath and adut socia care outcomes, 17 and it has been suggested that community hospitas may act as a hub for care integration and the provision of care coser to home. 14 More recenty, the NHS Engand Five Year Forward View 18 has caed for the remova of barriers in how care is provided, incuding between primary and secondary care and between heath and socia care, and a sma number of vanguard sites have incuded community hospitas as part of integrated primary and acute care systems and mutispeciaty community providers. 19 Against this background, there is thus potentia for community hospitas and reated service deivery modes to assume a more strategic roe in the oca heath economy to integrate service provision and thereby address some of the chaenges arising from service fragmentation in particuar. Furthermore, there is an opportunity to earn from the experiences of other countries in order to inform and hep advance the Queen s Printer and Controer of HMSO 2017. This work was produced by Pitchforth et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 1