Title: Models of Generalist and Specialist Care in Smaller Acute Hospitals: An Exploratory Study
Funder: Department of Health and Social Care

Abstract: The revival of general physicians, whose breadth of expertise enables them to manage both acute and chronic health problems, has been proposed as a way of better caring for the increasing numbers of older and more complex patients requiring emergency medical admission. This study will provide high quality evidence about the models of medical generalism currently in use in smaller acute hospitals in England. We will explore processes and models of care, their alignment with patient case-mix, their impact on staff, patients, costs, and patient and staff preferences. Aim The overarching aim is to identify the models of medical generalism used in smaller hospitals and explore their strengths and weaknesses from patient, professional and service perspectives. Objectives 1. To create a typology of the different models, considering workforce deployment, skills mix and service configuration, of generalist and specialist care used in smaller hospitals 2. To create a case mix classification that identifies patients who may benefit from generalist care and use this to describe and compare workload, resource utilisation and outcomes between hospitals and models of care 3. To assess the degree of alignment between patient case mix and medical generalist skills mix in smaller hospitals 4. To identify the strengths and weaknesses of the different models from patient, professional and service perspectives 5. To investigate the economic costs attached to different models 6. To assess the types, utility and relevance of potential variables and measures of outcome for a more detailed evaluation of the different models of medical generalism 7. To explore the different meanings, definitions and boundaries of medical generalism in the context of smaller hospitals Study Design: A 30 month mixed-methods study of smaller acute hospitals (trusts operating revenue < £300 M pa) in England [84]. We expect the sample will be 67.7% of the 75 eligible sites. Methods • Use of survey tools, document review, hospital site visits, a Day of Care survey and interviews to create and investigate a typology of models of medical generalism • Modelling and classification of the patient case-mix of smaller hospitals • Economic modelling of staff and patient costs associated with different models • Exploration of strengths and weaknesses of different models using focus groups of patients and healthcare staff, a discrete choice experiment and outcome analysis Outputs • Model of the patient casemix • Analysis of current staffing • Typology of models of medical generalism • Cost analysis of the different models • Summary of preferences from the discrete choice experiment • Potential outcome indicators to test models of care • Three future direction papers • Framework of knowledge for service/workforce planning and future research • Packages of findings for participating units The results will be immediately applicable to the 75 smaller acute hospitals in England, and relevant to policy makers. Aspects of this study have been designed as a prelude to a national quantitative and economic study of the effects of different models of generalist care, which is beyond the current scope. It will define whether there are sufficient differences between the models of care, define appropriate outcome measures (which are likely to be non-standard) and scope whether linkages between models of care and individual patients can be accurately made.

Lay abstract: People with multiple health problems, particularly those over age 65, are the heaviest users of hospital services. There are growing concerns that the care they receive from hospital doctors is not optimal for their needs. They are less likely, for example, to receive an accurate diagnosis or the most appropriate treatment. One reason for this is the trend for doctors to become more specialised, often focusing on the treatment of particular diseases or problems with single organs of the body, potentially leading to poorer care for patients with multiple diseases. As a consequence, there has been a call for a growth in the number of doctors who have broader range of skills – medical generalists. While people recognise the need for more medical generalists in hospital, we do not know how many more are needed. Nor do we have a clear idea of the number of patients who need this type of generalist care. Ways in which care is managed by generalist and specialist doctors in hospitals also vary, and we do not know whether some ways of working are better than others. We aim to answer these questions by looking at the different models of medical care used in smaller hospitals. For example, how many generalist and specialist doctors they employ and how they work together to meet the needs of patients. We have chosen smaller hospitals for a number of reasons. Most importantly, the people who use them tend to be older and more vulnerable and thus their need for generalist care is greater. This makes them an excellent place to explore the different models of medical care and how they impact on patients and staff. This study will be conducted over 30 months and will have five main work packages: 1. Understanding the way in which doctors work We will survey smaller hospitals to find out about the numbers of generalist and specialist doctors, and how they work together. The different models of care will be grouped and then investigated by visiting 15 hospitals and looking in more detail at processes of care. 2. Understanding the types of patients We will use data on people attending smaller hospitals, including their age and diagnosis to find out what proportion of patients would benefit from generalist care and what proportion need different types of specialist care. 3. Investigating the costs We will identify and compare the costs of different types of medical care. 4. Understanding the strengths and weaknesses of the different models We will talk to groups of staff, patients and carers about the different models to get their views and ask patients, carers and staff to choose their preferred model. We will see if we can find any differences between the different models by looking at what happens to patients and their health after their admission to hospital. 5. Analysis We will bring all these findings together to draw conclusions about the different models of medical care in hospital and how well they are meeting the needs of patients. We will make recommendations about how doctors work in smaller hospitals. The work will be undertaken by people with significant expertise in the different areas we are studying and the type of research we are undertaking. The results of this study will be shared widely through study reports, journals, websites, social media and events. We also use professional, NHS and policy networks to ensure that people who lead organisations and make policy are aware of our findings.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE