The teaching setting
What impact will the conversion of two district general
hospitals into teaching hospitals have? Views from the field
Jonathan Mathers,1 Jayne Parry,2 Sarah Lewis3 & Sheila Greenfield 4
Aim To gather opinions from a variety of healthcare
professionals in Birmingham and the Black Country as
to the potential impact of converting 2 district general
hospitals into teaching hospitals.
Methods Thirty-three semi-structured interviews were
conducted with healthcare professionals including
Directors of Public Health, Community Health Coun-
cil Chief Officers, Trust Chief Executives, medical
directors, trust managerial and consultant staff, junior
doctors and nurses. Interviewees were asked to outline
what they felt the major impacts of the conversion to
teaching status were likely to be.
Results Five main thematic areas were identified from
the interviews. Three of these related to the medical
students receiving their clinical training in the new
teaching hospitals, the teachers undertaking new or
Introduction
The National Health Service (NHS) Plan
The National Health Service Plan has indicated the
need to increase the number of doctors in the United
Kingdoms NHS.1 This is to be achieved through the
creation of up to 1000 more places at medical schools,
in addition to the 1100 places already expected to be
available by 2002. These changes represent a 40%
expansion in training places since 1997. This increase
will be supported not only by the advent of additional
1
Department of Public Health & Epidemiology, University of
Birmingham, UK
2
Department of Public Health & Epidemiology, University of
Birmingham, UK
3
Department of Epidemiology & Public Health, University College
London, UK
4
Department of Primary Care and General Practice, University of
Birmingham, UK
Correspondence: Jonathan Mathers, Project Officer, Department
of Public Health & Epidemiology, University of Birmingham,
Edgbaston, Birmingham, B15 2TT, UK. Tel.: 0121 414 6024;
Fax: 0121 414 2752; E-mail: Matherjm@medgp3.bham.ac.uk

Blackwell Publishing Ltd M ED I C A L E D UC A T I O N 2003;37:223232
additional teaching duties and the patients being
treated in the new teaching settings. Interviewees also
identified several organisational effects relating to the
new, established and non-teaching hospitals in the
locality and discussed potential impacts outside of
health care settings.
Conclusions The majority of views expressed by partic-
ipants were positive citing potential benefits from
developments in teaching provision. Areas of concern
generally related to the need for successful implemen-
tation of the changes within clinically focused environ-
ments rather than to the effects of teaching per se. The
impacts consequent to the reconfiguration of district
general hospitals to teaching hospitals should be eval-
uated by appropriately designed longitudinal studies.
Medical Education 2003;37:223232
new medical schools but also by the expansion of
undergraduate intakes at universities with existing
medical schools and the introduction of 4-year direct-
entry postgraduate medical courses.
This rapid expansion in student numbers necessitates
a parallel increase in clinical teaching capacity that
cannot be accommodated by existing teaching hospi-
tals. There must therefore be an increase in capacity
outside of the traditional teaching hospital base, inclu-
ding the designation of new teaching hospitals. The
subsequent change in organisational emphasis within
acute and community trusts that take on this role might
reasonably be anticipated to impact substantially on the
clinical staff, students and patients who work, train and
are treated in these settings.
For future policy development it is important to
understand what these impacts will be in order to
emphasise the positive influences of the teaching role
whilst mitigating against potential adverse effects.
However, at present there is no appropriate evidence
base that examines the impact on service provision and
quality of care following the transition from district
general hospital to teaching hospital, from which to
223
224 Impact of conversion of two district general hospitals into teaching hospitals
Key learning points
Currently there is a paucity of evidence relating to
the impact on district general hospitals of the
change to teaching hospital status.
Interviewees felt that influences of the teaching
function were potentially wide-ranging, with stu-
dents, teachers and patients liable to be affected.
Organisational issues such as staff recruitment and
retention, resource allocation, service provision
and research were also held as important.
Influence outside of healthcare settings was con-
sidered unlikely.
There is currently an opportunity to examine the
influence of the undergraduate teaching function
through appropriately designed longitudinal stud-
ies.
gain such insights. A review of the literature published
in 1998 found no research looking at the effect on
patient outcomes of a non-teaching hospital changing
to a teaching hospital.2 No systematic reviews, trials or
pre-post comparisons were identified. The authors have
updated this review3 and have similarly found only
cross-sectional comparisons of teaching and non-teach-
ing hospitals that methodologically are inadequate to
inform this debate. These studies cannot be used to
infer what would happen following the conversion of a
district general hospital to a teaching hospital. Further-
more, the studies identified concentrate on differences
in patient outcomes and treatment modalities and do
not address the organisational issues that are likely to be
fundamental to the success or otherwise of teaching
expansion. A study in the United Kingdom4 has
suggested that district general hospitals can provide as
good, if not better, teaching as teaching hospitals
however the study suffers from methodological limita-
tions in that the introduction of teaching was new to
teachers in both the district general and teaching
hospitals taking part.
The University of Birmingham Medical School
The University of Birmingham Medical School is part
of the Faculty of Medicine, Dentistry and Health
Sciences at the University of Birmingham a large
university located in the south of the city of Birming-
ham in the West Midlands region of England. The
University offers a 5-year undergraduate course leading

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J Mathers et al.
to the award of the Bachelor of Medicine and Bachelor
of Surgery degree (MB ChB).
The first 2 years of the course are primarily nonclin-
ical although students are attached to Firm 1 where
they spend 10 days each year in the community with
general practitioners and patients. In Year 3, students
undertake their first placements in the hospital setting
to gain basic clinical skills with placements in internal
medicine and surgery, followed by attachments in
medical subspecialities such as cardiology, neurology,
bone and joint disease, and oncology (Year 4). In their
final year, students undertake senior attachments in
internal medicine and surgery, and attachments in
obstetrics, gynaecology, psychiatry, paediatrics and gen-
eral practice.
Year 3 attachments in basic medicine and surgery
only take place in the designated teaching hospitals,
which at present are located within the city of
Birmingham. District general hospitals are used for
more specialist placements in the later years of the
course, including further placements in medicine and
surgery. Thus for the duration of their first clinical year,
students should only undertake placements in teaching
hospitals whereas in Years 4 and 5 placements in both
teaching and district general hospitals may occur.
Further information on the undergraduate course is
available on the University web-site (http://www.under-
graduate.bham.ac.uk/programmes/medicine.htm) and on
the Medical Schools home page (http://www.med-
web.bham.ac.uk).
The Black Country Strategy
As part of the national expansion of student numbers,
the University of Birmingham has launched an initiative
to graduate an additional 100 doctors every year,
termed the Black Country Strategy (BCS).5 The
strategy will increase the undergraduate intake from
218 in 1999 to 332 in 2003. To accommodate this
substantial increase in student numbers, basic clinical
teaching will expand from its traditional base within
hospitals in the city of Birmingham to placements in
acute and community hospitals elsewhere in the West
Midlands region. Specifically, this expansion will
involve hospitals in an urban area to the north-west of
Birmingham an area termed the Black Country.
The Black Country covers an area comprising the
towns of Dudley, Sandwell, Walsall and Wolverhamp-
ton. Two existing Black County district general
hospitals Sandwell and Wolverhampton will be rec-
onfigured as teaching hospitals from September 2001
and 2002, respectively, in order to provide training
placements for the expanded undergraduate intake.
Impact of conversion of two district general hospitals into teaching hospitals
Assessing the impacts of the BCS
Despite being familiar terms to clinical students and
tutors alike, Teaching Hospital and District General
Hospital are rather difficult to define precisely. Litera-
ture reviews have revealed no universal definition of
either hospital type. However, certain characteristics are
associated with each: Teaching Hospitals are tradition-
ally affiliated with medical schools, they receive
significant input from academic and professorial
university staff and are perceived to be sites of cutting
edge medical research. In contrast, district general
hospitals tend to be more peripherally based, receive less
support from the Medical School and University and
employ fewer academic staff.
Within the West Midlands there is now a unique
opportunity to evaluate the impacts of the transition of
a district general to a teaching hospital not only on the
organisation and delivery of secondary care services,
but also on the staff and students who work and train in
these settings. However, given the paucity of evidence
available to inform such research, the specific issues
that could most usefully be investigated are at present
unclear. We therefore sought to gather a breadth of
opinion from a variety of healthcare professionals, likely
to be affected directly or indirectly by the proposed
organisational changes, in order to scope the potential
impacts and so inform the subsequent research agenda
for the evaluation of the BCS. This was done using
semi-structured interviews.
Methods
Study population
The interview sample was purposively designed to
include a multidisciplinary group of interviewees likely
to be affected by the BCS. Those asked to take part
were the Regional Director of Public Health, the
Directors of Public Health (DsPH) and Community
Health Council (CHC) Chief Officers in the four health
authorities covering the Black Country (Sandwell,
Walsall, Wolverhampton and Dudley), and a range of
healthcare and managerial professionals working in
secondary care NHS Trusts. The NHS Trusts
approached to take part in the research were chosen
to reflect current and future variation in involvement
with undergraduate teaching. They thus included one
of the Black Country acute district general trusts newly
designated as a teaching hospital, one Black Country
acute district general trust not designated as a teaching
hospital, one Black Country community care trust and
one established Birmingham teaching hospital. Within

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J Mathers et al. 225
each of these Trusts a range of personnel were asked to
participate. These included the chief executives, med-
ical directors, the general managers of surgery and
medicine, consultant surgeons and physicians, junior
doctors and nursing staff. Consultant staff were iden-
tified via discussions with the Chief Executives and
approached to take part. Junior doctors and nursing
staff were identified following discussion with other
appropriate individuals, e.g. postgraduate tutor, direc-
tor of nursing.
Interviews
Twenty-eight individual interviews and 5 group inter-
views were conducted (number of participants range
25 in each group). The group interviews involved
junior doctors and nursing staff. Group interviews
were conducted with these participants as initial
discussions with the liaisons detailed above suggested
that this was the most practicable way of arranging
interviews with these staff. In all, 4 DsPH (including
the regional DPH), 3 CHC Chief Officers and 36
secondary care personnel were interviewed (see
Table 1).
Interviews were semistructured with pre-agreed
prompts for specific content areas. Content was
established by the research team and by feedback
received during a pilot phase where the interview
format was tested on a small convenience sample of
healthcare professionals and academics. The final
interview content is listed in Table 2.
In order to gain the optimum use of the interview
time participants were provided with a short interview
brief at least 1 week prior to the interview date. This
gave an explanation of the research project, interview
format and content. Participants were asked to consider
the impacts of the BCS prior to the interview. The brief
did not list the interview topics.
Interviews typically lasted 30 (range 2050) min-
utes, were tape recorded with consent and were
carried out by 2 of the authors (JM and SL). Both
authors are non-medical and were present at each
interview during which they alternated between con-
ducting the interview and recording hand written
notes as a back up to the recordings. At the start of
the interview participants were asked whether they had
read the interview brief and whether they understood
the main elements of the BCS and the purpose of the
interview. Interviewees who had not read the brief or
who wanted to re-read it were given time to do so
prior to commencing the interview. At the start of the
interview a very broad question was used to allow each
respondent to outline what they felt the major impacts
226 Impact of conversion of two district general hospitals into teaching hospitals J Mathers et al.

Table 1 Secondary care interviews by

DGH to become a Established Community Hospital Trust
Teaching Hospital DGH in Teaching Trust in
in the BC the BC Hospital the BC Total

Chief Executive 1 1 1 1 4
Managers 4 2 1 0 7
Consultants 2 3 2 0 7
Medical Director 2 1 2 1 6
Junior Doctors 5 2 1 0 8
Nursing Staff 0 4 0 0 4
14 13 7 2 36

of the BCS would be. Interviewees were thereby
allowed to introduce topics that they felt to be
relevant. Following the initial question interviewees
were prompted in detail regarding issues they had
raised and were asked about other topics contained in
the interview schedule. All interview topics were
covered with each respondent but the level of detail
was dependent on the responses given by each inter-
viewee. This was felt to be the most appropriate and
productive interview format due to the multidiscipli-
nary nature of the interviewees and the rationale for
the study, i.e. to identify the breadth of opinion
regarding impacts.
Data analysis
The recordings of the interviews were transcribed for
analysis. The transcripts were first analysed independ-
ently by 2 of the authors (JM and SL). Results were
then compared and discrepancies in interpretation
resolved with reference to the interview transcript.
The results of this process were validated independ-
ently by a third author (SG) who read the interview
transcripts and then the results of the analyses.
The analysis of the written transcripts was based on
the processes of decontextualisation and recontextual-
isation.6 That is, we sought to identify specific elements
of each transcript that related to the thematic structure
of the interview, explored these in more depth and
sought out similar elements in other transcripts
(decontextualisation). We then established that the
patterns emerging from these abstracted segments were
consistent with the context in which they were made in
the original interview (recontextualisation). Thus, each
interview transcript was read in its entirety and
substantive statements were highlighted in accordance
with a crystallisation analysis style.7 The transcripts
were then re-read and related statements were abstrac-
ted and grouped under appropriate headings guided by
the theoretical framework that structured the interviews
(as shown in Table 2).8 Results coded under each
heading were compared. Those statements of a similar
nature were grouped and variant or divergent codes
were noted. Each interviewee was given a unique study
number. Where quotes are presented, this number is
cited.
Data presentation

The results presented only represent the range of

Table 2 Semi-structured interviews
opinions that were expressed during the interviews
and do not explore any commonalities or contradictions
Content of interviews evident between either professional groups or hospital
settings included in the interview sample. The interview
Workload methodology and sample were specifically designed to
Staff morale scope the potential range of impacts, rather than to
Evidence-based medicine
Organisation of services logistics
provide a framework for detailed comparative analysis.
Health outcomes The results presented represent the range of themes
Recruitment and retention of staff that has emerged from the process.
Resources
Research
Patient satisfaction Results
Implications for medical students
Implications outside of healthcare settings, e.g. employment The themes arising from the interview results are
grouped into 5 categories (Table 3).

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Impact of conversion of two district general hospitals into teaching hospitals J Mathers et al. 227

Black Country would provide an abundance of

Effects on the students
Two subcategories emerged from the interviews relating
to the potential effects of the strategy on the medical
students training at Birmingham. These were the
influence of the Black Country as a teaching setting,
and the potential impact on the quality of teaching given
to undergraduates.
Training in the Black Country
Three of the 4 Directors of Public Health felt that the
students in being exposed to a deprived and cultur-
ally diverse population in the Black Country, would
gain a greater appreciation and understanding of the
impact of the socio-economic and cultural environ-
ments in determining health and health care seeking
behaviour. Interviewee 4 made this point particularly
forcefully;
I think the medical education in this country is
********* awful. In the sense that it does not really
reflect the true needs of the population which these
medical students will go to take care of. I think
many doctors at least will not have experienced the
kind of poverty and social problems we have in
Town A, and if you assume that 90% of doctors at
medical schools these days go on to work in places
like Town A isnt it dreadful that universities train
students with no exposure to those kind of prob-
lems. (Interviewee 4)
It was also suggested that experience in the Black
Country teaching hospitals would expose students to
more general run of the mill medicine. Here they
would have more opportunity for hands on experience
than in large teaching centres of excellence which
undertake more specialist work, and where the stu-
dent-to-patient ratio would be higher. Consequently
graduates would be equipped with more relevant
practical experience. One group of junior doctors
suggested that the relatively high levels of morbidity
and mortality amongst the patient population in the
learning material.
Teaching quality
Some participants expressed concerns regarding the
quality of the new teaching provision and the rapid
increase in numbers of undergraduates at the medical
school. Worries centred on the fact that the new
teaching Trusts must provide high quality teaching
capacity in a short space of time and that appropriate
teaching staff may not be immediately available. This
was seen as a potential source of student frustration if
the increased capacity in the medical school or new
Black Country placements were seen to dilute teaching
quality.
I suppose the big downside might be the fact that the
medical school is going from in effect another 100
students and whether that kind of an injection of
people is going to mean that it is very impersonal and
can it maintain quality and its like a lot of these
businesss that expand too rapidly then collapse
because theyve got the quantity but havent got the
quality They had to have the extra capacity and its
just being assured that extra capacity can come up to
the mark that is required in a very short space of
time. (Interviewee 3)
Other participants believed that the initiation of
performance management of teaching from the medical
school through a quality assurance programme would
ensure that high quality teaching would be maintained
in the new teaching hospitals. One manager was
concerned about the potential consequences for post-
graduate teaching quality as a result of the time
required for undergraduate teaching.
Effects on teachers
With regard to the effects on the clinical staff under-
taking the new or additional teaching responsibilities
the emergent themes related to the following areas:

Table 3 Five main thematic areas

Effects on students
Effects on teachers
Effect on patients
Organisational effects
Wider implications
The effect on medical students who receive their clinical training in the Black Country teaching hospitals
The effect on those personnel undertaking new or additional teaching duties in the Black Country
teaching hospitals
The effects visible to patients attending the new teaching Black Country Trusts for care
The potential effects on new, established and non-teaching hospitals in the Black Country and
Birmingham
The potential impacts outside of healthcare settings

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228 Impact of conversion of two district general hospitals into teaching hospitals
continuing medical education and evidence-based
medicine
morale and motivation
workload.
Continuing medical education and evidence-based
medicine
The majority of interviewees felt that teaching was a
stimulus for continuing medical education and required
clinicians to keep up to date and critically appraise
their current practice. Teaching was also seen to be an
impetus for the implementation of evidence-based me-
dicine and the clinical governance agenda. Some inter-
viewees went on to conclude that services, quality of care
and potentially patient-centred outcomes would im-
prove as a result of these influences. Other developments
inherent in the implementation of the BCS such as
improvements in information technology, access to the
virtual campus learning materials and investment in
educational resources were perceived to facilitate the
practice of evidence-based medicine. Some partici-
pants suggested that changes in clinical practice would
filter through both to non-teaching medical staff who
would be influenced by their teaching counterparts
and also to other healthcare workers such as nurses.
Morale and motivation
Virtually all of the interviewees who commented on
staff morale and motivation felt that teaching was
enjoyable for staff, and would act as a new source of
motivation and add variety to everyday work. If
teaching status improved the ability of the Trust to fill
vacant positions this was also seen as a positive
influence on staff morale. The corollary, however, was
that if teaching requirements were not adequately
resourced and overall workload was thus increased,
this could have a negative impact on staff morale.
Interviewee 36 felt this was a possibility;
It doesnt take long for people to work out their
SIFT or teaching increment is not filtering through
to them and they still have to work just as hard and
still doing their teaching as well (Interviewee 36)
It was also suggested by participants in the estab-
lished Birmingham teaching hospital and by one DPH
that tension may be created as a result of new teaching
posts within both the new and existing teaching trusts if
there was a disparity in the allocation of protected
teaching time amongst staff. One junior doctor was also
keen to stress the need for the number of junior doctor

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J Mathers et al.
hospital positions to match the expansion in student
numbers if lack of career choice was not to impact
adversely on the future graduates morale.
Workload
Many of the secondary care interviewees in each of the
Trusts were concerned that the teaching would result in
heavier workloads if the teaching requirements were not
adequately staffed and resourced. Potential sources of
additional workload included time for teaching ses-
sions, keeping up to date, extra administrative duties
and potential increases in the number of referrals to a
secondary care teaching service. If additional workload
resulting from teaching and from the competing prior-
ities associated with teaching and clinical throughput
were not adequately resourced, it was believed that the
quality of one or both of clinical workload or teaching
was likely to suffer.
Its one thing that people are particularly anxious
about because the more formalised teaching becomes
the more teaching there is to do and the more that
may take people away from the service aspect.
(Interviewee 21)
However other respondents, whilst recognising these
potential problems, felt that appropriate support for the
introduction of undergraduate teaching, for example
through the provision of additional teaching monies
and consultants posts would mitigate any adverse
effects on workload.
Effects on patients
Most comments regarding influences on the doctor)
patient relationship were positive, suggesting that
patients would benefit from the presence of undergra-
duate trainees. Interviewees thought that patients
would be generally enthusiastic about their role in the
teaching process and being able to contribute to the
education of future doctors. The extra time and
information from the extended consultation required
to accommodate teaching would enhance patient sat-
isfaction. Students were also felt to be an additional
source of patient information:
I think it is probably generally beneficial. There are a
few patients who object to students and being looked
at by students but quite a lot do like it, particularly
because they often get their diseases explained
better I mean there is a little bit more time if you
have got students thereand also the students talk to
Impact of conversion of two district general hospitals into teaching hospitals
the patients more and are often a source of informa-
tion about the illness. I think the patients get a better
deal. (Interviewee 1)
However, some participants, including one group of
nurses, thought that patients may be uncomfortable
with a student present and with the number of people
present during examinations and consultations, and
that this needed to be recognised.
Institutional effects
Interviewees identified four main areas at Trust level
that would potentially be impacted upon by the change
to teaching status. These were:
recruitment and retention of healthcare professionals
resource allocation
service provision subspecialisation
research activity.
Recruitment and retention
Interviewees were virtually unanimous in the opinion
that the move to teaching hospital status would have a
positive impact upon the ability of the Black Country
Trusts concerned to recruit and retain medical staff. In
addition to an expansion in the consultant base with the
input of teaching monies, participants suggested that
the ability to recruit and retain staff within existing
positions would be greatly improved, especially within
specialties which are difficult to recruit for. This was
because teaching hospital positions were perceived to
be more attractive and to be of interest to candidates
with academic and research interests. Interviewee 43
thought that this was already having an impact:
Its helped us already in recruiting good doctors who
want to come because there is teaching available and
the good doctors encourage more good doctors and
we very much want that to continue. (Interviewee 43)
If students had a good experience during attachments
at the new teaching hospitals that was seen as a potential
impetus for them to return there for postgraduate
training. Two interviewees hoped that if more students
from local ethnic minority communities could be recrui-
ted to the Birmingham course, service provision could, in
the long term, become more culturally sensitive.
Resource allocation
Several participants thought that teaching status would
act favourably for the new teaching hospitals with
regards to resource allocation. In addition to the

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J Mathers et al. 229
injection of Service Increment for Teaching (SIFT)
monies the new status was seen as a positive influence
on funding decisions with the possibility of increased
resource allocation. It was also suggested that the
hospitals would benefit from an increase in research
monies:
Well traditionally it follows doesnt it. Money follows
students. (Interviewee 15)
Some participants however, felt that the conversion
to teaching hospital could adversely affect other hospi-
tals. In particular, two participants in the established
Birmingham teaching hospital were worried that the
creation of new teaching hospitals might affect the
future allocation of teaching monies to their Trust, and
one CHC chief officer was concerned that the BCS may
impact adversely on those Black Country Trusts that
were not teaching hospitals with regards to future
recruitment of staff, resource allocation and service
provision. The interviewee felt that this would have
potentially negative impacts for the catchment popula-
tions of those trusts.
Service provision subspecialisation
Changes in service provision and development of
specialist services were seen as a possibility. The forces
initiating such changes would include the increased
consultant base and ability to provide a wider range of
services (including staff with particularly specialised
interests), and the teaching hospitals as a focus for
service development in the Black Country. Interviewee
1 was particularly worried that if there was excessive
subspecialisation this could reduce the accessibility to
more general services for local populations:
The problem area is that these guys will become
specialists and start to bring work in from all over the
place and the Town X residents are squeezed out by
their special interests and you end up with the ivory
tower medicine with the local people not getting such
a good service on the sort of bread and butter stuff and
it is certainly true that in the past that happened to
parts of Birmingham who were around the teaching
hospital. (Interviewee 1)
Research
An increase in research activity was seen as a likely
consequence of the new teaching activity. The intro-
duction of new teaching staff with research interests
and the new teaching status of the Trusts were thought
to improve the chances of successful research bids and
230 Impact of conversion of two district general hospitals into teaching hospitals
involvement in multicentre research projects in the
West Midlands. However, one participant did not think
that this would happen automatically and that it was
dependent on the new teaching Trusts attracting staff
with the ability to attract research funding.
Wider Implications
Most interviewees when asked about the potential
implication outside of the healthcare settings felt that
there would be little impact on the local economy via
the expansion in student numbers. Participants sugges-
ted that although there may be some additional posts
created as part of the strategy most new consultants
would live away from deprived areas and that the scale
of job creation was insufficient to significantly affect
some of the wider determinants of health.
Discussion
In the absence of relevant evidence to assess the likely
impacts of converting two district generals to teaching
hospitals, we undertook this study in order to identify
the issues that may arise following the introduction of
the teaching function into an NHS secondary care
Trust. The predicted impacts of the reconfiguration of
services reported are likely to be relevant at other
English universities and hospitals where similar expan-
sions of undergraduate training are taking place.
The interview sample was specifically designed to
access a range of healthcare professionals in different
settings with direct or indirect interest in the BCS. This
was intended to enable an assessment of the widest
possible range of opinion, experience and potential
impacts from this particular group of professionals. The
interview format was also designed in order to gain the
widest range of results from a multidisciplinary group of
interviewees. Interviewees were given the opportunity
to consider issues prior to the interview and also to
introduce topics that they felt to be pertinent at the
start. This allowed the interviews to cover issues not
specifically included in the predesigned interview con-
tent and also allowed participants to discuss in detail
topics which they deemed to be the most pertinent from
their professional standpoint.
The purposive nature of the sampling framework and
the interview design allowed the investigators to iden-
tify the range of potential impacts but was not designed
to enable direct comparisons of results based on
professional background or involvement with the
BCS. This is because the interview format did not
result in every topic being covered in the same depth
with each interviewee. This would have required much

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J Mathers et al.
longer interviews than were practicable, or for a
narrower range of interviewees to be covered. In
addition, comparative analysis between the range of
professionals and settings included in the study would
have necessitated a larger interview sample. Detailed
comparison of the results according to background
would be inappropriate from the data collected and has
therefore not been attempted.
For students, placements in the Black Country were
felt to be beneficial, offering access to a relatively
deprived population and a less specialised case mix with
more opportunity for hands on experience. Such beliefs
would appear to assume that the pre-existing medical
school teaching hospitals serve less deprived popula-
tions, have more specialised case mix and higher
student)patient ratios, so offering fewer clinical learn-
ing opportunities than the new teaching units. This is
an assumption that is currently being tested by the
authors in order to make recommendations regarding
the optimum use of hospital teaching capacity for the
benefit of medical students.
Interviewees expressed concerns about the ability of
the new teaching Trusts to deliver high quality teaching
from the very beginning of the introduction of under-
graduate placements. As previously discussed, other
studies have reported positive findings regarding the
teaching quality in district general hospitals.3 However,
the generalisability of such findings to the situation in the
West Midlands, where there will be a disparity between
the experience of the new and established teaching
hospitals in the Black Country and Birmingham in
delivering basic clinical (third year) training, is not clear.
We would suggest that the impact of the increase in
student numbers on teaching quality should be carefully
monitored.
Despite concerns about the delivery of their teaching
commitment, there was a general consensus among both
existing and future teaching hospital staff that becoming
a teaching hospital would bring about improvements in
the quality of patient care. Such a perception, however,
is not substantiated by any published literature.2,3
One mechanism by which interviewees believed that
teaching hospitals achieved high quality service provi-
sion was through the increased practice of continuing
medical education and adoption of evidence-based
medicine by staff involved in the delivery of the
undergraduate curriculum. Interviewees postulated that
the implementation of evidence-based medicine strat-
egies would lead to improved clinical care and thus
improved patient outcomes. However, whether
evidence-based medicine is associated with improved
quality of care at an institutional level has not yet been
established. A recent systematic review of the effective-
Impact of conversion of two district general hospitals into teaching hospitals
ness of critical appraisal teaching suggested that
although there is evidence that critical appraisal teach-
ing has positive effects on participants attitudes, know-
ledge and skills there are gaps in the evidence as to
whether it impacts on decision-making or patient health,
or on satisfaction. Furthermore, the authors added that
if a benefit was seen it was unclear whether the size is
large enough to be of practical significance.9
Even if evidence of better outcomes can be seen
when comparing teaching with non-teaching hospitals,
we should be cautious about extrapolating the findings
of cross-sectional comparative studies to a single unit
experiencing organisational change over a period of
time. As has been shown when comparing outcomes
among high and low volume clinical units, high
volume cancer units may produce better outcomes not
only because practice makes perfect but also because
of other more subtle organisational factors.10 Similar
factors may confound the straightforward comparison
of teaching and non-teaching hospitals.
Aside from clinical outcomes, patient satisfaction is
increasingly being recognised as an important aspect of
quality of care. Studies which have explored patient
perceptions of being involved in student teaching in
general suggest that it is a positive experience.11,12 Such
a belief was echoed by participants in this study.
However, as noted by some interviewees, not all patients
enjoy being the subject of student teaching. New (and
existing) Trusts should have clear policies in place to
respect patient wishes and to ensure all participation in
teaching is voluntary and with full consent.
Comments by participants were generally positive
about the effects on the newly established teaching
hospitals with regards to future recruitment and
retention of staff, resource allocation, service provi-
sion specialisation and the conduct of research. The
only negative comments surrounded the potential
development of specialist services in the new teaching
hospitals and accessibility issues for bread and butter
local services and the potential to negatively affect
non-teaching hospitals within the Black Country.
These issues should be closely monitored in order to
alleviate any negative consequences and to inform
similar developments elsewhere in the UK.
The replacement of secondary care services with
teaching hospitals was generally suggested, by study
participants, to be a positive intervention with regard to
the health care provided to local communities.
However, although intuitively appealing, this assump-
tion may be flawed when considered within the broader
context of health and healthcare provision. The devel-
opment of teaching hospitals within Sandwell and
Wolverhampton raises the question of the consistency

Blackwell Publishing Ltd M ED I C A L E D UC A T I O N 2003;37:223232
J Mathers et al. 231
with the implementation of other strategies for health
within these localities. For example, communities in
both areas are targets of the national New Deal for
Community policy a regeneration-orientated initiative
that seeks to bring about improvements in health
through changes in the physical and socio-economic
environments (for example improved housing, better
schools, tackling poverty).13 A tension may become
apparent between those interventions targeted towards
tackling the root causes of ill-health, and those based
upon enhancing the delivery of high tech medicine.
Furthermore the increased costs associated with teach-
ing hospitals may distort the local health economy,
resulting in proportionally less spending on primary care
and community services. Such changes may impact
adversely and disproportionately upon individuals al-
ready experiencing deprivation and social exclusion.
The majority of the views expressed in this study were
positive citing potential benefits from the developments
in teaching provision. Similar benefits have been repor-
ted following evaluations of the introduction of commu-
nity-based teaching; students express satisfaction with
their placements1416 and acquire good levels of basic
clinical, problem-solving and management skills.4,17
General practitioners also report satisfaction with their
involvement in community-based teaching both from a
personal point of view (skills are sharpened and practice
kept up-to-date) and also from the perspective of their
patients, many of whom welcome the opportunity for
longer consultations and a more detailed explanation of
their illness when students sit in on consultations.14,18
However, concerns have been raised more recently
about the sustainability of high-quality community-
based teaching and in particular, the impact of increasing
student numbers within the existing infrastructure.19,20
Similar concerns have been expressed in this study in
that the potential negative effects on staff were not
always related to the effects of teaching per se but rather
to the need for successful implementation of the changes
and the accommodation of the enhanced teaching role
within clinically focused environments. Strategies to
successfully channel change are well-documented in the
business literature.2123 Handy has argued for three core
ingredients to be central to any change management
process: clarity and feedback on over-arching goals, the
acceptance of a climate of experiment with tolerance of
failure; and open, full and frank communication whilst
recognizing the importance of territory within the
organization and local ownership of ideas.21
The importance of Handys ingredients for the
management of transition from district general hospital
to teaching hospital maybe self-evident, but in them-
selves are no guarantors of success. The current changes
232 Impact of conversion of two district general hospitals into teaching hospitals
in undergraduate training through the reconfiguration of
district general to teaching hospitals should therefore be
viewed as the introduction of as yet untested novel and
complex organisational and health technologies. The
impact of such interventions on staff, students and
patients both in the hospital and in the wider community
setting should be evaluated as would be required for the
introduction of any other novel medical intervention.
Murray has recently reviewed the challenges of under-
taking evaluations of complex and multifactorial inter-
ventions, and suggested that educational research could
learn from the experiences of health service research-
ers.24 We would support her call for techniques devel-
oped in other disciplines to be adopted for use in the
evaluation of educational change for the balance between
teaching, research and clinical practice is difficult to
achieve, and should be informed by the best available
evidence. There is now a window of opportunity to
gather this evidence.
Contributors
JM contributed to the design of the research, conducted
the research interviews (along with SL), analysed the
study data (along with SL), wrote the initial draft of the
manuscript and contributed substantially to revisions of
the manuscript. JP had the idea for the research,
contributed to the design of the research and contributed
substantially to revisions of the manuscript. SL contri-
buted to the design of the research, conducted the
research interviews (along with JM), analysed the study
data (along with JM) and contributed substantially to
revisions of the manuscript. SG contributed to the design
of the research, contributed to the data analysis and
contributed substantially to revisions of the manuscript.
Funding
There was no external funding for this project.
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Received 7 February 2002; editorial comments to authors 17 April
2002 and 18 July 2002; accepted for publication 30 August 2002.