Two years after Our Health, Our Care, Our Say promised to shift care away from the acute sector, community hospitals are redefining how they provide services. Alison Moore looks at the emerging models and asks what has held up progress

When the white paper on care outside the acute sector came out two years ago, it was greeted with enthusiasm by many supporters of community hospitals.

Our Health, Our Care, Our Say talked of a new role for community hospitals, with a shift in resources away from the acute sector, and warned primary care trusts against closing them without justification.

Typical of the coverage at the time was a story in The Times which said "it could be a lifeline for a host of community hospitals under threat of closure".

But two years on, have community hospitals found a niche and secured their future?

Community Hospitals Association vice president Helen Tucker says that at one time the association knew of 156 community hospitals - just under half the total - that faced closure or loss of significant services. In the previous decade 3,000 beds had been lost.

Now there are fewer hospitals facing closure or downgrading, although there are at least 15 local campaigns to preserve services - including in Suffolk where plans to close two community hospitals are being considered by the health secretary.

But finding a new role for community hospitals has taken longer than expected. "We are probably not much further forward than we were when the white paper came out," Ms Tucker says.

The financial crisis affecting the NHS, the determination to get it back into balance and PCT reorganisation all held up progress. Junior health minister Lord Darzi's review of the health service and the need to clarify the government's vision of the structure of the NHS might also have affected primary care trusts' willingness to press on with radical plans, says NHS Alliance chief officer Michael Sobanja. "But it is beginning to gain momentum, people are sitting down and thinking about what they want."

NHS Alliance chair Michael Dixon suggests the real breakthrough will come through practice-based commissioning and with the involvement of local people, which should find a compromise between local support for hospitals and the demands for cost-effectiveness.

"I think [that] when local people are the commissioners, they can square that circle. But there is no doubt that most community hospitals need to up their game in terms of providing what is required," he says.

Future forum

Some PCTs have come up with radical new visions of the future that have won local support. Cumbria PCT is looking to co-locate hospitals with residential care homes run by the local council, providing care on site for a vulnerable group while preserving other services. But it is likely to leave the exact configuration of services to each locality.

In Wells-next-the-Sea in Norfolk the local hospital is now run by a community group, with some services provided by the NHS and some payable privately. It also runs healthy lifestyle events, such as walks, and hopes eventually to reopen inpatient beds. Ironically, Norfolk PCT has recently decided to close 20 beds in other community hospitals in the county.

The perception that community hospitals are still under threat has continued in many areas, sometimes even when PCTs are trying to develop their role. This may be a reflection of the differing vision of what community hospitals are: are they about services or beds? "It comes back to what you mean by community hospitals, that's almost the $64,000 question," says NHS Confederation deputy policy director Jo Webber.

An increasing number of community hospitals are "bed-free" - in effect becoming polyclinics. In Hampshire, a planned£18m community hospital at Fareham will provide a plethora of services but probably without inpatient beds.

But while individual facilities without beds may be appropriate in some cases, there is scepticism that entire health economies can function without community-based beds. Royal College of Nursing head of policy development and implementation Howard Catton argues that something is needed between acute and home-based care.

He points to evidence of increasing numbers of over-75s being readmitted to acute care. "The not unreasonable conclusion to draw from that is that people are either being discharged too early or that there are not the community services in place to support them," he says.

In theory, community hospitals can provide easily accessible services often available only in the acute sector, such as diagnostic facilities or outpatient clinics. In practice this can be hard to achieve. Efficient use of staff, especially in shortage specialties, the need for diagnostic facilities to be provided on site and transport issues may all preclude this. Acute trusts may also be reluctant to lose income and prefer solutions where they retain control of services and clinicians, albeit providing these services in different places.

But developing hospitals dependent on providing other people's services may not be a solution to the financial pressures. Helen Tucker points out that they risk becoming a venue for other businesses, rather than a business in their own right.

"Where community hospitals have revenue of their own tends to be around beds and minor injury units - and these are often the areas under threat," she says. Part of this is to do with how payment by results works, she says, although the DH is working hard to resolve this. Split tariffs could help reward community hospitals for the work they do that benefits the acute sector, says Dr Dixon.

One solution is for the community hospital to employ either consultants or GPs with a special interest. Dr Dixon points to Tiverton and District Hospital in Devon, where many of his patients can be seen by such GPs without entering the acute sector.

But the white paper was also about developing services that could be provided in the patients' own homes, which risks being seen as an either/or choice with hospital-based services.

More talk, less action

Many PCTs want to strengthen these services, in some cases redeploying staff who previously worked in hospital. But this is not always straightforward: staff may not wish to work in the new structures or may lack the skills or personal qualities needed for what can be a significantly different job. Concerns about safety and travelling time, together with changed working practices and times, can be a barrier.

Mr Catton says: "What we are picking up nationally is more talk than action in terms of moving staff into the community." He points to a trend of PCTs reviewing the productivity of their community staff and professionals' fears that this could be about reducing capacity rather than increasing it.

One of the big issues for nurses, Mr Catton suggests, will be whether they continue as NHS employees - for example, if a community hospital is run by a social enterprise company. "There [is] a host of really significant pay and conditions issues [that has] to be resolved and can be a very significant deterrent,' he says.

The white paper also envisaged a shift of resources to accomplish all this, something that Ms Webber believes is happening gradually.

However, with this year dominated by the ambitious 18-week "referral to treatment" target, progress may be slow - unless community hospitals can show their work contributes to the acute sector achieving the target.

The government says it is already putting money into community hospitals and services: at the end of last year it announced£132m of investment in new hospitals and "super-surgeries". But the Community Hospitals Association says the definition of what is eligible for funding under the five-year£750m programme has been wide, and some money has gone to GP surgeries rather than what many people would see as a community hospital.

Southern comfort: how Devon and Cornwall are making it work

Both Wiltshire and Devon primary care trusts serve counties with a large number of small towns and relatively rural communities. Historically both have had many community hospitals.

But the two PCTs are developing radically different models of care - which both believe are in line with the thrust of the white paper.

By June, Wiltshire PCT will have reduced its inpatient beds at community hospitals by nearly three quarters, from 200 to 54. One of its predecessor PCTs shut an entire community hospital and others are likely to close. But it has set up 11 multi-professional teams to provide 24-hour care in people's homes.

There should be financial benefits too. "Community hospitals eat money," says PCT provider arm managing director Jenny Barker. But the driving factor was to provide better care for the many patients who did not need to be in hospital if they received high quality services at home.

There was some local and political opposition to the changes to the hospitals and staff had concerns about working in the new teams, which delayed their implementation. The teams now work 7am-10pm, with on-call access all night being piloted in one area with the GP out-of-hours provider.

The PCT avoided any redundancies for its clinical staff, although some chose to work elsewhere. It is still facing a judicial review over changes to one hospital.

"The key to success is [to involve] people all through the process and [to be] honest with them, even if things go wrong," Ms Barker says.

In contrast, Devon PCT is running 21 community hospitals with around 450 beds. Chief executive Kevin Snee has plans to strengthen these hospitals.

He sees them doing more of the work traditionally undertaken in acute centres - with day cases, plans are to shift up to a quarter of work into the community in some areas. Chemotherapy and blood transfusions could also be done there, he says. Some of this could involve acute clinicians working in community hospitals. "The focus should not be the infrastructure but the service delivery," he says.

Four urgent care centres, working with the GP out-of-hours service and with access to diagnostic services, will also be set up as a mid-point between medical investigation units and accident and emergency.

But he also argues that some work done in community hospitals could be provided in the patient's home, and he aims to strengthen services to do this - along with enhanced working with social care.

This plan sees community hospitals as a lynchpin in the NHS. But Dr Snee says: "They will only be sustainable if there is a significant shift of activity and resources into community hospitals."