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Nov
10

The Future Role of Hospitals

The guidance is out.   CCGs and foundation and non-foundation trusts are required to produce a detailed two year plan by March and an agreed 5 year strategy.  Build in to your thinking 4% efficiency targets, a 1.9% tariff deflator and a £3.8bn transfer to social care.  Some challenge.

To be fair the size of this challenge has not gone unrecognised.  The joint letter from NHSE, Monitor, TDA and LGA states that, ‘CCGs, foundation and non-foundation trusts… must develop and implement bold and transformative long-term strategies and plans for their services, otherwise many will become financially unsustainable and the safety and quality of patient care will decline.’ 

A key part of these plans needs to be clear thought and strategic thinking as to the role of hospitals in 5 years’ time.  Somehow CCGs and hospitals have to agree this to create a joined up strategy.  What won’t work is a set of individual plans from hospitals and CCGs that make overly bold savings predictions and lack any vision or strategic thought as to what the future will look like. 

The Nuffield Trust has outlined the consequences of continuing down the road we are currently on.  In their submission to the Health Select Committee earlier this month (here) they warn that the government must think about how to deal with a situation in which hospital trusts start to become unsustainable in larger numbers than the current system is designed to address.  Their research shows no evidence of a step change in productivity which could enable the NHS to be able to do more for less at a rate to stay within the available financial envelope.

But what appears to be lacking is a set of clear options from which local health economies can choose to frame coherent thoughts about the future of hospitals.  There is a real absence of strategic thinking to support the production of these 5 year plans.  And before the writing must come the thinking.

So where do we start?  As good a place as any is an article in the Bulletin of the World Health Organisation (2000) by Martin McKee and Judith Healy, ‘The role of the hospital in a changing environment’ (here).  Despite being written 13 years ago, it still provides a helpful background to the role of the hospital, and highlights the complexities of any efforts to introduce change.  As they put it, ‘Hospitals pose many challenges to those undertaking reform of health care systems. They are, quite literally, immovable structures whose design was set in concrete, usually many years previously. Their configuration often reflects the practice of health care and the patient populations of a bygone era.’

The debate around the future of hospitals tends to centre around the size and configuration of hospitals, as entities in their own right.  To merge or not to merge.  Arguments swirl around improvements in outcomes through increasing specialisation, and greater economies of scale through fewer, bigger hospitals.  Alternatively smaller hospitals produce greater access and reduce inequalities.  The impact of technology is argued both ways.

This debate, however, operates in isolation from reform of the wider system.  And it is not alone in this.  Discussions about the future of general practice equally have an insular focus, without painting any sort of picture of how the system as a whole might operate in the future (as we have previously discussed here).

The most recent discussion on the role of hospitals has come from the Future Hospital Commission of the Royal College of Physicians, when in September it produced, ‘Future Hospital: Caring for Patients’ (here).  Within this there are some interesting recommendations, including:

  • Hospital services to operate across the whole health economy, and for hospitals to be responsible for specialist medical services inside and outside the hospital
  • Care delivered by specialist medical teams in community settings
  • A ‘Clinical Coordination Centre’: an operational command centre operating across the health economy with links to acute, specialist and primary care and community teams

This builds on what was alluded to by Keith Palmer in his 2011 report for the Kings Fund, ‘Reconfiguring Hospital Services: Lessons from South East London’ (here), which states,

Reconfiguration should focus on achieving the best patient outcomes and patient experience for all NHS patients, and on narrowing the quality gap between the best and worst performers. This is best achieved by designing reconfiguration to drive accelerated adoption of best practice models of care in as many services as possible. This in turn is best achieved by designing reconfiguration along patient pathways involving specialist/tertiary hospitals, district general hospitals (DGHs) and primary care providers.’

And if we recall Porter and Lee’s premise in ‘The Strategy that will fix Health care’ (see here) that care needs to be organised into units responsible for the full care pathway of a patient’s condition, then it seems to me that we are left with two real choices in our thinking on the future of hospitals.

The first is that hospitals take the lead on the delivery of pathways across whole systems.  As organisational entities their boundaries are extended as far as primary care, and different hospital  organisations would lead on different pathways (i.e. specialist hospitals would have lead responsibility for more specialist pathways).

The second is that hospital organisations become organisations analogous to shopping centres, whereby they would run the estate and maybe also staff for other organisations that have lead responsibility for pathways, who are able to use the facilities as appropriate.  So just like a shopping centre provides the space and facilities for different retail organisations to use, so hospital organisations could provide theatre and ward space and facilities for care pathway providers.

Clearly this needs thinking through, and I am sure there are other options that I have not thought of.  But what I do think is important is that we make the best possible use of the next 6 months to consider these issues carefully, that we spend some real time collectively thinking in a way that is not constrained by organisational boundaries, and that we produce plans with a vision that we believe is achievable in the tough climate within which we are operating.

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