Community hospitals: still a viable option?BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3581 (Published 26 July 2017) Cite this as: BMJ 2017;358:j3581
All rapid responses
Community hospitals are an international vexata quaestio and their closure is more and more requested, but what are the results? First is the increased access to the central hospitals, the increased time needed for a diagnosis, the increased time for families when elderly patients who are in hospital need care and stay 50 or more km far away from home and when the family cannot care there is a need to ensure a carer with special costs. These are costs of families and not of the NHS, but they cannot be ignored. But when we consider also the NHS costs (increased hospitalization, delayed diagnostic times…) it could be useful to rethink health policies considering also personal and family costs.
The experience of the mental health dept of Ascoli Piceno (Asur Marche) in the Ambito sociale XXIV of Marche Region shows that a continuous shared common work of MHD, GP, Amandola hospital, families and all people giving social support to patients (Italian national health system reform of 1978 established this integrated work sul territorio i.e. at patient’s home and community) can reduce acute psychiatric accidents (last compulsory hospitalization was 2103), can reduce the amounts of volunteer hospitalization (in over 120 psychotic patients from 1985 to 2014 we have recorded 5-8 hospitalizations a year), can reduce the need for admission to sheltered facilities (4 over 30 years). All these are economic (material) costs, which we found reduced throughout a 30 year retrospective survey (1985-2014).
The non economic (immaterial) values of this integrated work (a continuous shared common work of MHD, GP, Amandola hospital, families and all people giving social support to patients) are mainly the increased chance for a safe expression of patients in their home and community, the possibility of true integration (based on and respecting their own possibilities), the potential to help our most vulnerable patients who do not feel themselves refused or tolerated but an active part of a community, in respect of personal objective and subjective possibilities of tailored work.
Until 2016 August 24th, first earthquake in middle Italy, this common work gave such results, not only in reducing health system costs but also increasing social and personal satisfaction (measured with qol-proxy and sf 36). Further result is the growing network of sheltered facilities in Ambito sociale XXIV of Marche Region: Montelparo has cared for adult autistic patients for several decades, Amandola has also had for several decades a therapeutic community for addicted patients, in 2011 Force opened a sheltered facility for 12 guests (only one from Ambito territoriale XXIV) and in July 2016 Comunanza did open a new facility for 20 patients; in Montefortino there is also a sheltered facility for young people without families who arrive by sea in Italy.
Another result of this kind of shared work is the integrated domiciliary care system, surrounding Amandola hospital, which has reduced hospitalisations for patients with complex clinical and psychosocial complaints, ranging from acute decompensated COPD to anxiety, heart failure, and urinary tract infection, through the work of specialists and paramedics.
In conclusion, the common work in Ambito territoriale XXIV shows that a care model based on shared integrated work (Amandola hospital, MHD, specialists families and all who can give social support to the patients) “facilitates adaptation to the varied needs of diverse community environments, creating a crucial access point to engage patients in effective care outside of institutional settings” and can indice a “true integration of patient-centered clinical care with social supports, delivered in the home, for the most vulnerable patients”.
The health consequences of the earthquake of August 24th last year, which caused closure of Amandola hospital, remain to be seen, especially in the most vulnerable patients, until the opening of a new hospital.
Competing interests: No competing interests
Yes of course they are, and many commissioners/providers/commentators accept that is the case. In the absence of suitable beds for intermediate care, for example, the problem of delayed transfers of care from acute hospital settings becomes harder to solve. And sub-acute care for elderly patients with dementia, who don't always need to be in an acute hospital, is made more difficult to provide. There is not, however, a strong evidence base for the retention of community hospitals, so I suppose the zombie of closure will continue to threaten their survival.
Competing interests: No competing interests