Are US-style 'hospitalists' the answer for 24/7 working?

One of the key points that emerged from HSJ and Clever Together’s discussion around 24/7 working was the creation of a new role of a “generalist”. A generalist is a doctor who can act as an interface between all traditional care settings, helping to facilitate early discharge. 

The idea might be a new one for the NHS, but it is already an established practice in the US. Its pioneer is Dr Robert Wachter, who coined the word “hospitalist” and is considered the pioneer of the hospitalist system.

Defining role

In the hospitalist model of patient care, the majority of patients who are admitted to an American hospital are primarily cared for by the generalists in the hospital themselves, and these generalists are called hospitalists.

Dr Wachter says: “The hospitalist takes over the patient’s care when they are admitted from the emergency department and they remain that patient’s doctor until the patient is discharged. So in many ways they are like a GP, except in a hospital.”

He adds that the hospitalist system emerged because the older model of care, wherein a Medicare doctor would also be a hospital doctor, was inefficient. “Patients in the hospital were too sick, the place was too crowded and the doctors were too busy in the office. There were a lot of specialists but no one to pull it all together,” he says. 

‘Clinicians in the NHS have contracts that make it difficult to shift resources around, so I’m not convinced that a change like this could happen as smoothly in the NHS as in the US’

In contrast, in the hospitalist system there is a “doctor who sees the bigger picture; who has taken care of all parts of a patient’s illnesses; is a patient’s advocate; and can synthesise all of the information”.

He believes this is a better model than GPs coming to the hospital or specialists managing the patient on a specialty ward.

Describing how the system evolved, Dr Wachter says: “Individual hospitals started adopting this model in the early 1990s.” When he wrote an article in the New England Journal of Internal Medicine in 1996, coining the term hospitalist, “the idea came into the public consciousness and took off from there”.

He adds that the switch to the hospitalist system was organic in the US. “In the US, the healthcare system is more nimble [compared to the UK] as we are not a single system and it’s not largely controlled by the government. It operates more on a free market model; and when new innovation emerges that people believe will improve quality or efficiency − or is simply better − the system naturally transforms itself quickly.”

UK observations

Dr Wachter has been a US-UK Fulbright scholar at Imperial College London, so has had a chance to observe the NHS closely. Asked if the NHS can adopt a hospitalist model, he says: “These kinds of large changes are more challenging in the UK as they have to be endorsed by the NHS, the royal colleges, Department of Health and several other organisations.

‘It’s partly human nature that doctors and nurses don’t want to work overnight but adequate payment can solve that’

“Clinicians in the NHS have contracts that make it difficult to shift resources around. So I’m not convinced that a change like this could happen as smoothly in the NHS as it happened in the US, wherein it didn’t require our equivalent of the royal college to endorse it; it didn’t require change in the government’s payment method or the number of physicians training for it.”

Growing take-up

He states that in the US, this is the fastest growing specialty, up from a few hundred doctors 15 years ago to 40,000 today, though he is quick to add the results differ from hospital to hospital. Citing the example of his own hospital in San Francisco, Dr Wachter says “large, urban hospitals are quite efficient”.

“They have consultants and physicians in the hospital overnight and even the nursing staffing overnight is quite good,” he continues. “Patients get very good care at night and I know this in part because my mother was hospitalised at my own hospital and I observed very carefully what happened at day and night times. I felt comfortable leaving her at night because I thought the care was good.

“But I have been to smaller hospitals in the countryside where consultants are at home while nurses call them [on the phone], and the level of nursing staffing is not as good at night as it is during the day.”

On being asked what the key barriers are in implementing 24/7 working, he says it’s “mainly economic”, adding: “It’s partly human nature that doctors and nurses don’t want to work overnight but adequate payment can solve that. Also, in order to adequately staff overnight, one has to spend more than what it costs to have the same staffing during the day.”

‘Years of the NHS operating in a top-down, prescriptive, rule based kind of model has created a sense of helplessness on the part of clinicians’

Another area of concern, according to Dr Wachter, is that night staffing and work has not been given the “institutional priority” it should have.

He elaborates: “Administrators and leading doctors and those who really control the way resources tend to flow usually aren’t there at night. So during the day there are lots of people around scrutinising the quality of care and if something goes wrong, they can decide to spend money on it to make it work better, which is not the case during the night.”

Varying engagement

If he had to single out one thing that the US does better than the UK, it would be the difference in the level of engagement by frontline clinicians in quality improvement.

“In the UK, the staff, particularly physicians, do not feel they have the ability − and in some ways even the responsibility − to make the system work better. That’s partly because of years of the NHS operating in a top-down, prescriptive, rule based kind of model, where for every problem there is a set of policies. This has created a sense of helplessness on part of the clinicians that there’s really not much they could do to change things.”

In a good system in the US, he adds, “There is a sense of enthusiasm and ownership by the doctors and nurses that is really quite impressive. It wasn’t always so but in the last 10 or 15 years, clinicians have stepped up their game and recognised that if the system is going to work better, then we need to make that happen. It can’t be left to administrators or managers.”  

‘There is a need to tell the public honestly: “This is what we can do with the resources we have and here are the gaps,” and not overpromising’

A recipient of the John M. Eisenberg Award, the US’ top honour in patient safety, Dr Wachter is known as a national leader in patient safety and healthcare quality. Even though he has written two books on the subject, and has been a member of the advisory boards of several governmental and private companies, he ironically points out that “when you hear an American talk about our system, you should take it with a grain of salt as our system is broken”.

“The quality of care is variable and safety is not as good, and we fear overspending and wastage might bankrupt our country,” he says.

The UK, he says, has a different set of issues: “There is certainly waste in the system and some misallocation but there is also a need to tell the public honestly: ‘This is what we can do with the resources we have and here are the gaps,’ and not overpromising.”

Different models

The two countries have very different models of healthcare. The UK’s national health service is financed by taxpayers, while the US uses a variety of mechanisms such as private insurance, tax dollars and employer contributions, but Dr Wachter is of the view that “we all have something to learn from each other”.  

“Patients’ illnesses don’t respect the time of day so we need to figure out a way of staffing hospitals at night to provide the care that is needed,” he says.

“Staffing can be less − it perhaps should be less than it is during the day − but it should be adequate to meet the needs of patients. Otherwise it’s not an ethical way to run a healthcare system.”