Maintaining an intermediate level of hospital care

The doctors felt that CHs are suitable for the care of patients who require an intermediate level of hospital care. In the absence of clear guidelines on patient admission criteria, and as CH doctors differ in clinical experience and skills, there is variation in which patients are admitted or referred. The basic principle was that patients who require competences and resources not available in CHs should be referred to a general hospital. The doctors stated that CH patients primarily consist of elderly people following three healthcare pathways: acute patients, postoperative rehabilitation patients and end-of-life patients. Acute CH patients are typically elderly individuals with multiple comorbidities. Common diagnoses among such patients include pneumonia, COPD and cardiac failure. Patients with unclear symptoms are admitted for medical investigation and to address any non-medical factors. Patients not adequate for CH care are those that initially need extensive hospital resources, for example, acute diagnostics with CT scanning, intensive care, surgery, acute cardiovascular interventions or constant surveillance. Doctors report that many patients are sent to CHs for early postoperative rehabilitation and while waiting for municipal care, with hip and pelvic fractures as common diagnoses. Many CH patients are admitted for end-of-life care. The doctors stated that although home is the preferred place to die in for most end-of-life patients, advanced palliative home care is not available 24/7 for those living far from CHs. In such cases, patients may be admitted to the CH for high-priority care. The hospital rooms intended for palliative patients allow relatives to stay overnight to offer familiarity and CHs were compared with small hospices.

When comparing patient safety between CHs and general hospitals, the doctors suggested factors that favour CH care, including smaller wards and the broader competence of experienced CH nurses, who better understand patient needs and preferences. They emphasised the importance of considering the whole patient when deciding on the optimal level of hospital care. One doctor stated that because CH doctors are involved in patient follow-up care, they are more proactive in discharge planning, which may reduce rehospitalisations compared with general hospital.

The doctors expressed frustration regarding the lack of basic medical technology services in CHs, which led to unnecessary hospital transfers. They desired more POC tests to reduce delays caused by waiting for laboratory results, particularly for vital tests like sodium, potassium and creatinine analyses, which were lacking in some CHs and could result in referrals to general hospitals. In addition, chest X-ray examinations for inpatients were infrequent, requiring radiology nurses to commute and so making them available only a few times per month. While some doctors had access to valuable ultrasound examinations for diagnostics, this resource was not available to all CHs and doctors.

The doctors perceived CH care to be cost-effective, offering high-quality care for patients with fewer resource needs than general hospitals and they stated that CH beds are half as costly as general hospital beds. However, budget constraints often lead to CH bed cuts, increasing costs for ambulances and undermining economic benefits.

The doctors discussed the future of CHs, expressing a fear of resource cuts leading to closures and staff loss in sparsely populated areas. They suggested that the CH model should be expanded to towns for better care and cost-effectiveness through generalist-provided intermediate hospitals. Many found it perplexing when complex home situations placed elderly patients in highly specialised hospital wards where staff lacked expertise on comprehensive care in multimorbid patients.

Providing local service and feeling of safety in the community

The doctors stated that CH patients and their families are generally satisfied with local care, feeling more secure and calm than in hectic hospital settings. Many patients prefer CH care to hospital transfers, with some documenting this preference in their medical records. The doctors argued that patients are often familiar with the CH staff and find it easier to visit the CH than a hospital. In addition, patients who require frequent administration of medical treatment appreciate it being possible for this to be done locally, rather than at a hospital. One doctor emphasised the significance of patient satisfaction, even in the absence of medical-outcome analysis. The doctors described taking pride in CH palliative care, emphasising the ability for relatives to visit, teamwork among hospital staff and familiarity with patients. They argued that referring patients with palliative needs to general hospitals is generally a less optimal approach than keeping them in CHs, where patients and relatives expressed gratitude for the quality of care received. The doctors acknowledged, however, that those who are dissatisfied with the care may not openly express their concerns to their doctor, and instead share their dissatisfaction elsewhere.

The community seems to value CHs greatly. When one CH ward was closed, there was a prolonged occupation of the CH to pressure politicians to reopen it. The interviewed doctors anticipate similar reactions if there are future attempts to close CH wards. The constant availability of medical expertise was believed to contribute to a sense of safety within the community.

The doctors stressed the importance of local cultural understanding, which reassures patients by acknowledging their situations and living conditions. Familiarity with geography aids in planning follow-up care and reducing patient travel. Understanding the local population’s mentality enhances comprehension of patients and their challenges.

Most CHs are situated in Sápmi, the historic Sámi settlement area. Understanding of Sámi culture and language in CHs was deemed to be an important aspect of caring for Sámi patients, particularly elderly people. CHs near the Finnish border also serve Finnish-speaking patients. In one CH, Finnish-speaking assistant nurses are used instead of telephone interpreters, unless the doctor speaks Finnish.

Being an interface between different providers of healthcare and nursing care

The doctors highlighted the central position of CHs in patients’ healthcare journeys, offering primary and secondary care and collaborating with general hospitals and municipal healthcare. The doctors also described other staff finding the complexity of the tasks in a CH ward challenging, but it also allowed them to acquire broad competences over time. Many staff members had community insight, aiding patient care and discharge planning. The doctors described engaging in respectful counselling calls with hospital specialists who guided them in CH patient care to avoid unnecessary referrals. However, some staff in larger hospitals were unaware of CHs’ inpatient care provision, and derogatory attitudes, mainly from subspecialists in tertiary hospitals, were described.

With regard to CH patients with changing nursing needs at discharge, the doctors emphasised the importance of coordinating with municipal needs assessors. The small CH context was seen as favourable as it brings assessors closer to the care process and involves shorter decision paths and improved workflow. The familiarity among team members was said to foster collaboration and prevent problems being passed onto others.

However, the doctors recognised the vulnerability of small communities with regard to staff shortages: if, for example, a needs assessor is absent due to illness, this can delay decisions for patients and prolong hospital stays.

Some of the rural GPs had served as doctors in local nursing homes and had regular interactions with municipal nurses about residents’ health. Separate patient records between the municipality and region were described as the cause of challenges, such as reliance on verbal information causing the risk of data loss and patient harm.

The doctors questioned the division of municipal and regional responsibilities for older patients’ care. Bureaucracy in interactions with municipal decision-makers was said to prolong hospital stays.

As the doctors were interviewed before the COVID-19 pandemic, they discussed using telephones, photographs and videos to bridge distances in healthcare. E-health solutions were seen as increasingly relevant in rural areas in order to reduce the costs and workload of having doctors on call every night and weekend in each CH. Systems of doctors remotely assessing patients via video were described, as was the possibility of admitting patients to CH care from distance. However, there were worries that distance assessments could increase ambulance transports and compromise patient safety in CH wards.

The doctors generally supported relevant use of telemedicine, but some cautioned against viewing it as a healthcare saviour, warning about false security affecting patient safety.

Striving to see and understand the patient in their context

The doctors compared CH doctors to general hospital specialists, arguing that the latter are highly specialised while the former have broader skills but lack organ-specific knowledge. It was suggested that CH patients with complex conditions benefit from comprehensive care by CH doctors, who can manage diverse medical issues. The doctors also reported collaboration with hospital specialists when they needed to overcome limitations in CH patient care. They emphasised the advantage of being able to observe changes in patients over time, enabling more informed and patient-centred decisions to be made based on comprehensive information. This was contrasted with hospital doctors, who often encounter patients primarily in acute conditions. For this to succeed, doctor’s continuity was deemed essential. Increased use of medical locums in place of regular rural GPs may raise medical risks and result in unnecessary transfers to general hospitals. However, there was recognition that knowing a patient too well could also be a risk and that another doctor with fresh eyes may discover what you miss. The doctors stressed the importance of a holistic perspective, that is, prioritising patients’ well-being and focusing on the psychosocial context, wishes and quality of life over mere medical conditions. This approach was perceived to be beneficial for multimorbid elderly patients in hospital care and enriched the doctors’ understanding of diffuse symptoms.

With regard to older multimorbid patients, the doctors emphasised the need to evaluate the appropriate level of care. In palliative cases, discussions about medical limitations, including cardiopulmonary rescue, were considered to proceed more easily when patients knew the doctor and staff well.

Facing advantages and disadvantages of rural working conditions

The doctors described the diversity of their jobs and additional tools available to them, especially the ward, as aspects that made their roles more satisfying than working as a GP in a town. One doctor doubted that they would work as a GP without the positive reinforcement of having a ward, which they felt helps to balance the challenges of outpatient care. The ward also allowed them to further develop their medical competences. The doctors described satisfaction in providing optimal hospital care at CHs. When discussing the potential of CHs to relieve overcrowded hospitals, one doctor expressed this patient-centred aspect: “We shouldn’t offload; we should take care of our patients.” (Doctor 7).

It was, however, acknowledged that not all GPs are suited to the diverse array of responsibilities found in a rural CH, which require the ability to handle uncertainty and stay up to date with a variety of treatment guidelines.

The doctors reflected on the universal problem of understaffing in rural areas. Some CHs appear fully staffed on paper, but factors such as holidays, education and on-call service are often not considered. Surprisingly, in some CHs, the doctor’s work in the ward is not counted during medical staffing calculations. Many CHs cannot maintain their on-call rosters due to understaffing, impacting daytime work, and so the temporary solution of using medical locums and hired nurses becomes permanent. Although one doctor claimed that most medical locums were skilled, others were strongly against having locums in place of permanent colleagues.

A rural medicine addition to the GP specialist training programme in Sweden was developed in 2009. Some of the interviewed doctors were in the midst of their rural specialist training at this time, while others had already completed it. Some of the older doctors had been rural GPs before the programme and valued a specialised profile that addresses specifically rural medical issues.

Sweden lacks mandatory continuous medical education (CME) for specialists, leaving updating knowledge to individual choices. Some doctors deem this problematic, while others value hands-on clinical experience over organised CME due to the ease of online knowledge access. The doctors emphasised the importance of regular training for rare acute medical situations. CME courses were described as being beneficial on the basis that they facilitate experience sharing with colleagues and foster informal knowledge exchange and camaraderie. The doctors stated that they personally limited their CME applications, as their absence would place additional responsibilities on their colleagues or locum physicians. Distance from educational centres poses another challenge, demanding extra travel days.

Making medical decisions and taking action far from a general hospital

The doctors described the process of deciding whether to admit a sick patient to the CH or refer them to a general hospital. They described prioritising providing good and safe care, making the choice based on individual assessments rather than predefined criteria, and patients sometimes refusing to go to a general hospital despite recommendations.

Medical decisions about care limitations in multimorbid and end-of-life patients were crucial. Doctors described prioritising symptom control over unnecessary and painful investigations and treatments that might not benefit the patient.

Managing resources and logistics was felt to be essential. Some doctors stated that they are always aware of the location of the local ambulance as, when on a call, it does not return for several hours. One doctor reflected that this would not be a concern for town-based doctors. At times, the doctors described moments of uncertainty when grappling with ethical dilemmas such as deciding on alternative transportation for a patient despite the ambulance being recommended. Such a decision is made when the perceived risk to the patient is less than that posed to the community in terms of an emergency occurring and the ambulance being absent. This decision, made due to limited resources, entails personal and professional risk for the doctor, especially if the patient’s outcome is unfavourable. The doctors value the CH ward, which they feel ensures patient safety and helps retain ambulance availability. By admitting some patients for observation, they avoid sending them home with potential deterioration and subsequent ambulance calls. Patients who require ambulance transport but not urgently can stay in the CH ward until the next day, saving the ambulance during the night.

Rural CH GPs must stabilise life-threatening situations before hospitalisation, exposing them to challenging scenarios. The exposure to emergency situations was seen as a barrier to doctor recruitment and was felt to lead to feelings of constant stress. However, the experienced doctors reported increases in confidence in handling different scenarios, and support from hospital specialists over the phone lessened the feeling of exposure.

Young doctors may feel hesitant to consult specialists, but an experienced rural doctor emphasised the importance of seeking advice when needed. The doctors also highlighted the competence of the ambulance team and nurses, who provide vital support in difficult situations. While rural GPs might not be competent in every situation, they know when to seek additional help.

Misjudging situations, for various reasons, can lead to patient harm, which can be traumatic. The doctors had various coping strategies for adverse outcomes: “If I wasn’t here, it would be even worse” and “I did not make the patient ill, it depends on their having a disease” (Doctor 5).

Additionally, living and working in a rural area were felt to present social challenges. While knowing patients had medical benefits, it meant never being anonymous, and gossip was described as troublesome. Treating relatives and friends, especially with intimate examinations, was felt to be undesirable in such close-knit communities. One doctor described patients approaching them at home or in public with medical inquiries.