Posts Tagged ‘Reconfiguration’

We must deliver care in new, proven ways

By Mike Broad - 4th July 2014 12:10 pm

A Health Select Committee report says the NHS is facing “one of its greatest challenges” in dealing with patients with multiple long-term conditions, such as diabetes, asthma and cardiovascular disease.

Cutting back on hospital services before community services have been developed to support people with long term conditions would be a “recipe for disaster”, MPs say.

Here’s the key reaction:

Professor Simon Bowman, president of BSR

“BSR views the publication of this report as a valuable step in raising awareness of long-term conditions, and we support the Committee’s view that government departments should work together to tackle the issue of long-term conditions management in a strategic way, and with the involvement of patients, clinicians and other stakeholders embedded  throughout.”

NHS Confederation chief executive Rob Webster

“This new report from the Health Select Committee adds further weight to the clear and growing consensus that if health and care services are to continue to meet people’s needs, we must deliver care in new ways.

“Care must be built around individuals to help them maintain good health and be independent for as long as possible. This inevitably means more emphasis on community care. There is widespread agreement among health and care professionals, clinicians and service leaders that, where clinically appropriate, this is the right approach.

“The need to change the way we deliver healthcare is unarguable.

“Transformation of the scale required cannot be done while NHS organisations are continually having to pare their finances to the bone. NHS leaders aren’t pressing the government with an open-ended demand for more money for the health service. We know money is tight across the public sector. We are calling instead for certainty. Fixed Parliaments give the opportunity for longer term settlements. A five year settlement for the NHS - or even better, a ‘decade deal’ - would give the health service certainty about its funding and enable service leaders to plan the right care for local people in the right place at the right time.

“Alongside getting the finances right, it is imperative that we change what we do and how we do it. Hand in hand with investment for transformation needs to be a genuine commitment from politicians to support the changes which are essential for the NHS’s future, and a similar commitment from the health service to be ready to change when needed.”

“Smaller NHS hospitals must change their model”

By Mike Broad - 16th June 2014 11:06 am

Small district general hospitals can survive and thrive but the way services are provided to local patients must change to guarantee quality care.

This is the finding of a report from regulator Monitor, whose economists analysed a comprehensive range of clinical and financial indicators to test whether any special factors affected the performance of hospitals with fewer than 700 beds (typically in trusts with an income of less than £300million).

The research found no clear evidence that smaller acute hospitals performed any worse clinically than larger counterparts.

However, the analysis showed that there is evidence that smaller providers may be starting to face greater financial challenges, with performance worsening more than the sector as a whole in the last two years.

The report concludes that size is likely to become more of an issue as hospitals face greater pressures to recruit staff to further improve the quality of care. Monitor recommends that the sector should:

- Identify new models of care for patients, for example re-designing services to improve the integration of care and move it closer to home

- Come up with creative ways to address the scale challenges, such as sharing staff with nearby trusts, using new technology, or building networks between smaller hospitals and major centres

- Make sure that the right balance is struck in local communities between redesigning services and making sure patients are treated near to where they live.

David Bennett, chief executive at Monitor, said: “People value their local hospitals and we wanted to understand the challenges that they face as the NHS takes on a potential £30 billion funding gap over the next decade.

“We found that smaller hospitals are facing increasing challenges but with the system’s support can continue to play an important role in the nation’s health service.

“Bigger isn’t always better and just merging or taking a ‘one size fits all’ approach to local health services is not the answer. We need to achieve the right balance between risks to quality and risks to access, and consider other constraints such as the impact of clinical specialisation to make sure patients continue to benefit from the local hospitals that they value so much.”

Terence Stephenson, chairman of the Academy of Medical Royal Colleges, said: “This is a valuable report and it has been welcome that colleges have been able to provide advice and input through the Clinical Advisory Group established for the project. Providing the right services for patients in the right place that can be financially and clinically viable is one of the NHS’s absolutely key challenges.

“It is clear from this report that that there are no simple conclusions or answers to these questions. But the report provides the service with a useful base for taking forward thinking and practical action.”

Monitor says it will now identify the new models of care that can better address the underlying causes of financial challenge at individual NHS providers and in specific local health economies. This will include understanding the economic impact of moving care out of hospital and the extent to which it might generate savings for commissioners.

Rob Webster, CEO of the NHS Confederation, said: “This important report provides additional weight to the view that we need to stop obsessing about the size of organisations and start thinking much more about models of care. Small hospitals have a future as part of a whole system approach to healthcare. Along with everyone else, small hospitals will have to adapt the range of services that they provide, and the ways in which they do so, as they continue to be part of the offer of local access to healthcare.”

Read the report.

A&E’s vital role should not be down graded

By Mike Broad - 22nd May 2014 9:59 am

Only 15% of attendees at Emergency Departments can be seen by a GP in the community without the need for Emergency Department assessment, claims research.

The research, commissioned by the College of Emergency Medicine and conducted by Candesic, finds that 85% of patients who visited A&E were there appropriately and that only one in seven attendees could have been seen within the community instead.

The college’s research significantly challenges the often quoted figure that “40% of patients who attend A&E departments are discharged requiring no treatment”.

The findings of the research arrive at a time when the delivery of emergency medicine faces a severe shortage of emergency medicine doctors, an increasing number of attendances, an unfair payment system to hospitals and a lack of accessible and effective alternatives to the Emergency Department.

Although the redirection figure of 15% is substantially less than the often quoted 40% it equates to 2.1 million attendances. This reconfirms the college’s call for the establishment of co-located Primary Care Centres - or Urgent Care Centres - to decongest Emergency Departments.

However, the difference between 15% and 40% is significant and represents around 3.5 million patients per year.

Of the 15% of people who could be seen by a GP the largest sub-group were young children presenting with symptoms of minor illness.

The group for whom redirection was least probable were the elderly.

The study finds that 22% of people could be appropriately managed by a GP working in the Emergency Department with access to the same resources.

A further 63% attendees within the Emergency Department needed the skills of a specialist emergency medicine doctor, and 28% were admitted to hospital.

The college says the data discrepancy should be viewed as an opportunity to design services fit for the future.

A&E Departments should be configured with access to co-located Primary Care Centres; GPs should work within A&E and use the Emergency Department facilities; there should be early access to specialist emergency medicine doctors.

Dr Clifford Mann, president of the College of Emergency Medicine, said: “The fact that only 15% of attendees at Emergency Departments could be safely redirected to a primary care clinician without the need for Emergency Department assessment is a statistic that must be heeded by those who wish to reconfigure services.

“Providing a more appropriate resource for the 2.1 million patients represented by this figure would substantially decongest emergency departments.

“Decongesting Emergency Departments is key to relieving the unprecedented levels of pressure placed upon them and improving patient care.”

This analysis is based on the records of 3,053 patients who visited twelve Emergency Departments across the country over a 24-hour period, and was collected on Thursday 20th March 2014 by Independent consultancy Candesic. The A&E’s were representative in terms of geography, age and case mix.

Outcomes must lead reconfiguration decisions

By Mark Newbold, CEO of the Heart of England NHS Foundation Trust - 1st May 2014 10:05 am

A new report by the Federation of Specialist Hospitals warns against compromising its members when reconfiguring services - suggesting their outcomes are among the best in England.

Dr Mark Newbold, chair of the NHS Confederation’s Hospitals Forum, comments on the findings:

“The Federation of Specialist Hospitals’ report articulates some of the concerns and recommendations voiced by our members.

“There is widespread consensus that clinical outcomes should guide any decision about reconfiguring specialised services, and evidence needs to be gathered of any efficiency gains resulting from centralising these services in fewer, larger centres.

“Any specialised services’ reconfiguration planned by NHS England must consider and address the full range of consequences. For instance, smaller providers may be destabilised if they lose specialist services, and this could impact on their ability to provide other, non-specialised, services to their communities.

“In each locality, the whole health and social care system must co-create a strategy which is appropriate for the area, and is both sustainable and capable of delivering the best outcomes for patients.

One size does not fit all, and this ‘place-based’ approach will ensure local need is taken fully into account.”

Reconfiguration: don’t cut specialist providers

By Mike Broad - 9:56 am

Plans to reorganise hospital services must recognise the unique expertise and class-leading outcomes of specialist hospital services, the Federation of Specialist Hospitals has warned.

The body is calling on NHS England to clarify its intentions regarding the reconfiguration of specialised providers in England.

The Federation cautions against a one-size-fits-all approach and emphasises the need for change to be driven by clinical considerations.

NHS England has suggested that it plans to reduce the number of providers of specialised services from 270 to 30 or fewer.

Since April 2013, NHS England is the sole direct commissioner of all specialised services with a related budget of about £13 billion, over 10% of the NHS’s total spend. Specialist hospitals carry out 250,000 procedures and 2.5 million outpatient appointments each year.

The report highlights the high performance of England’s specialist hospitals.

Professor Tim Briggs, chair of the Federation of Specialist Hospitals, said: “The Federation’s report highlights the excellent clinical and patient-reported outcomes achieved by specialist hospitals in both routine and complex services. In an NHS where the experience of the patient comes first, hospitals that deliver the best outcomes for their patients should be at the heart of the service.

“The FSH supports the reorganisation of specialised services, where there is a clear clinical rationale focused on providing high quality care. Reconfiguration of services, should concentrate provision in centres with the best outcomes for the relevant medical specialty, with appropriate sharing of this expertise through networks, rather than seeking to concentrate more services in just a few large hospitals.”

Moorfields Eye Hospital, for example, carries out about 330 drainage tube surgery procedures for intractable glaucoma each year. This involves the placement of a permanent plastic tube to allow fluid to escape from the eye. A 2012 audit found that the procedure had a success rate of 98% at Moorfields, compared to other centres where success rates are around 80%. The occurrence of complications was also significantly reduced to 3.4% at Moorfields, in contrast to 20% at some other centres.

93% of staff at The Christie who responded to the 2013 NHS staff survey reported that they would recommend the hospital to their family and friends. In a 2012 staff survey, 89% of staff at the Royal National Orthopaedic Hospital either agreed or strongly agreed that they would recommend the trust to their family and friends.  This compares favourably with the NHS staff survey national average, where only 63% of NHS staff said they would recommend treatment by their organisation to family and friends.

In December 2013, NHS England published guidance entitled Everyone Counts: Planning for Patients 2014/15 to 2018/19. This guidance included the statement of intent which anticipated the concentration of specialised services in 15 to 30 centres.

Very little information regarding these plans have been made available since the publication of the planning guidance.

No political willpower to tackle NHS challenges

By Mike Broad - 1st April 2014 10:07 am

Half of MPs (48%) fear a free NHS may be unsustainable if challenges facing the service are not tackled.

This is the key finding of a survey by the NHS Confederation - published on the first anniversary of the NHS reforms - which polled a cross-section of 100 MPs for their views.

The survey also reveals that 81% of MPs believe the NHS in their constituency needs to change to meet the needs of patients in the future.

Yet 65% say there is insufficient political will to permit change, and one in four say they would not back changes to their local NHS if their constituents are opposed.

Rob Webster, chief executive of the NHS Confederation, said: “These results reveal there is cross-party consensus about the need to make changes to the NHS and that there are doubts about whether there is the political will to do so.

“This comes on the back of our member survey published last week, that showed significant backing for change from NHS senior leaders, who voiced doubts that change will be achieved in the current environment.

“The resounding message from this survey is clear – we need an open and honest apolitical conversation between the public, patients, politicians and those delivering healthcare across our communities, about the future challenges facing the NHS.”

Dr Ian Wilson, chairman of the BMA’s representative body, said: “The government must not risk the NHS’ core value of being based on need, not ability to pay, purely because they are unwilling to take action and make the changes they admit are desperately needed.

“It is unbelievable that while eight out of 10 politicians agree change is essential, almost seven out of 10 say there is insufficient political will to allow this to happen.

“The reality is that the NHS is under intense pressure from a combination of rising patient demand and declining funding. Politicians must confront these challenges head on in order to ensure we can continue to deliver a high standard of care while remaining free at the point of use.”

MPs’ responses to the survey:

Q1. The NHS needs to change in my constituency to meet the needs of patients in the future

81% of all respondents strongly agree/agree

Breakdown by party:

Conservative – 85 per cent strongly agree/agree

Labour – 73 per cent strongly agree/agree

Lib Democrat – 75 per cent strongly agree/agree

Other – 80 per cent strongly agree/agree.

Q2. There is sufficient political will to permit such changes

35% of all respondents strongly agree/agree

Breakdown by party:

Conservative – 41 per cent strongly agree/agree

Labour – 23 per cent strongly agree/agree

Lib Dem – 51 per cent strongly agree/agree

Other – 40 per cent strongly agree/agree.

Q3. Any such changes are likely to be opposed by my constituents

43% of all respondents strongly agree/agree

Breakdown by party:

Conservative – 43 per cent strongly agree/agree

Labour – 46 per cent strongly agree/agree

Lib Dem – 38 per cent strongly agree/agree

Other – 20 per cent strongly agree/agree.

Q4. If the challenges facing the NHS are not addressed, then it may not remain free at the point of need

48% of all respondents strongly agree/agree

Breakdown by party:

Conservative – 53 per cent strongly agree/agree

Labour – 39 per cent strongly agree/agree

Lib Dem – 50 per cent strongly agree/agree

Other – 60 per cent strongly agree/agree/

Q5. What would persuade you to back changes to your local NHS?

Public support of plans by clinicians – 69 per cent of all respondents strongly agree/agree

Evidence the changes will improve patient care – 93 per cent of all respondents strongly agree/agree

Evidence the changes will save money – 53 per cent of all respondents strongly agree/agree

None of the above if constituents are opposed – 25 per cent of all respondents strongly agree/agree.

NHS must spend billions on reform or disappear

The Guardian - 13th March 2014 1:25 pm

Billions of extra funding will be needed for the NHS to help push through “painful and unprecedented” changes during the next parliament, the outgoing boss of the health service warns.

In a frank interview with the Guardian, Sir David Nicholson said that whoever formed the next government would need to give the NHS extra cash because it could not survive if it had to remain in the straitjacket of austerity-era flat budgets after 2015.

The money would be needed so the NHS can dramatically rationalise hospital services, and concentrate its specialist and GP services – allowing an NHS Nicholson calls “unsustainable” to ditch its outmoded reliance on hospital-based treatment and switch to a new model of community-based care.

Nicholson declined to say how much more cash he believed would be required, but another senior NHS leader privately suggested it could be up to £5bn extra a year for several years.

Read more in The Guardian.

Positive contract negotiations key to NHS survival, BMA says

By Dr Mark Porter, chair of BMA council - 3rd January 2014 6:42 pm

The period between Christmas and the January credit card bill can be one of nervous denial, but we eventually face up to our excesses and pay for them, in the gym or in the bank.

The NHS is in a different situation. The financial outlook is dire, but if there ever was any extravagance in the 25 years I have worked in the health service, I must have been off that day.

No, the NHS is struggling just to keep pace. A growing and ageing population, public health problems like obesity, and constant advances in treatment and technology are all contributing to push NHS costs well above general inflation.

The increases in costs may be inevitable – the Health Select Committee has estimated demand will grow at 4% per year – but the corresponding budget increases are not. In June, the Chancellor gave the NHS in England a rise of just 0.1% above general inflation between 2014-2015 and 2015-2016 – more than most public services but significantly less than the costs facing the health system. The allocations in Scotland, Wales and Northern Ireland are also tight.

The numbers overall are so bad that if the NHS were a country, it would barely have a credit rating at all. The Nuffield Trust has estimated that if the NHS budget continues only to keep pace with general inflation, there will be a shortfall of between £44 billion and £54 billion in England by 2021-2022, unless there are productivity gains.

But even with a 4% productivity gain every year, the funding gap would still grow to as much as £34 billion. It would take savage cuts to even begin to find this much money out of further ‘efficiency’ savings.

And efforts to generate savings to date don’t encourage optimism. We are now part way through the Nicholson challenge – the initial drive to find up to £20 billion recurrent of savings in England over the four years up to 2015. In the first year of the challenge, more than half of the £5.8 billion savings achieved were from reducing tariff payments to providers or cutting staff pay through freezes. The Commons Health Select Committee subsequently warned the government that neither were a ’sustainable form of efficiency gain’.

The National Audit Office said the NHS had made the ‘easiest’ savings first. They were certainly not easy for the doctors and other healthcare staff who were made to bear the brunt. And it was not easy for the patients and staff every time a vacancy is not filled, a ward is closed, or a clinic is cancelled.

However, it is beginning to be more widely recognised that more fundamental change is required. Though, not necessarily, the kind of change most of us would want. A senior NHS leader warned recently at a policy gathering that efficiency savings would not be enough in the years ahead, and that the NHS would have to ‘take out capacity’. That translates as cutting services to patients.

What are the alternatives? There have been some thoughtful and brave efforts to reconfigure services in ways that maintain or improve quality while also increasing efficiency, much of it thought up and led by clinicians. The transformation of stroke services in London is one such brilliant but rare example.

But such strategic approaches require clear and credible leadership to be successful. A major problem, in England at least, in that in a post-Health and Social Care Act world no-one really knows who is in charge. Too often, service change decisions are driven by a mishmash of political and financial imperatives, alienating the local communities that the services are meant to serve.

This is underlined by the government’s recent heavy-handed approach to facilitating service change – with legislation currently passing through Parliament that would give trust special administrators, appointed to run failing trusts, the powers to make changes to neighbouring trusts without consulting patients, clinicians or other providers.

So, what does that mean for our profession? Can we not bring evidence instead of prejudice to the problem?

The negotiations over changes to GP contracts in England for 2014-2015 show that a more strategic approach can deliver for patients and doctors while also improving efficiency. Our negotiators reversed the adverse impact of this year’s contract changes, which brought in unnecessary targets and excessive paperwork, and agreed changes that will enable GPs to deliver more personalised care for vulnerable patients to help them stay out of hospital.

The GP contract negotiations show it is possible to achieve efficiencies and still improve care, rather than having one or the other, or randomly knocking chunks out of the health service budget.

And that’s the point. The solutions are harder to find given the dire financial outlook, but if doctors are given the chance to find them, we can. And we must.

The year ahead will be shaped in many ways by the outcome of contract negotiations for junior doctors across the UK and consultants in England and Northern Ireland currently underway. Within the same cost envelope, we need to find a way of enabling doctors to provide the highest quality care while ensuring fair remuneration, meaningful development opportunities and a healthy work and life balance.

As part of this, we are looking at how best to tackle the ‘calendar lottery’ so that our patients can receive the same high standards of NHS care seven days a week. There are many barriers to overcome, but our recent position paper on seven-day services showed we are willing to take a lead.

One barrier that we need to get rid of as soon as possible is a perception in the media and elsewhere that doctors are part of the problem. We know that a huge proportion of consultants already provide emergency cover out-of-hours and some are regularly present, and as part of our work on negotiating a new consultant contract, we are finding out its full extent.

But the public needs to know this too. You will remember what happened when politicians made inaccurate and demoralising comments blaming GPs for the pressures on emergency care, and we must be alert to these kinds of attacks on our professionalism and integrity, and fight them with facts.

We also have to tackle bureaucracy. All too often, it saps our energy worse than a winter virus. In a survey we published in the summer, two-thirds of doctors said they had wanted to make changes but were held back by red tape or a lack of capacity or support. A similar proportion felt less empowered than they did the previous year.

At a special event we held to draw out the views of juniors and consultants – we have more planned this year – doctors said managers often seemed there mainly to enforce targets and find savings, and that they felt many managers regarded them as irritants in that process. We can no longer afford to have two tribes, because two tribes bring half the benefit to patients.

It is more than just a question of mutual respect. It’s also a willingness to step out of traditional roles and recognise that the financial constraints within which the NHS works are not just an issue for managers, and that good patient outcomes are so much more than a ‘clinical issue’.

It can all sound very aspirational. It is, but look what happens when it is missing. At Mid Staffs, where a managerial obsession with achieving foundation status became more important than anything else, where disengaged and disillusioned clinical staff did not speak out loudly enough, and patient care suffered terribly.

The problems at NHS Lanarkshire were not on the same scale, and an inspection report published earlier this month said clinicians and managers were working hard to do the right thing. But that report contained a very worrying detail – that staff did not always report risks to the delivery of patient care because they believed that management would not take action.

Both cases, although very different, show that giving up can be harmful.

Clearly it is time to put medical professionalism back at the heart of the NHS, and in 2014 we will be starting a major campaign to put modern professional values – like integrity, evidence-based practice, and patient-centeredness – to the fore.

The campaign will aim to empower and support doctors, who want to lead services and shape change. It acknowledges that doctors often feel change is forced upon them, and they want the freedom to make services better for patients.

This will drive our contract negotiations and help doctors take the lead in major issues like seven-day services.

We will also promote the value of the profession, a value that is not always reflected accurately by government or the media. Part of this will be about showing the extraordinary things that doctors do in their ordinary working lives. They happen so often that even we do not always notice them, and we certainly don’t do enough to promote them.

And the campaign will also aim to shape NHS reform so that medical professionalism is liberated. This means that not only will doctors be willing to lead and improve, but the system enables them to do so.

We look to learn from best practice in the health service and outside it, and how those who raise concerns can be supported and protected.

Our work on professionalism is new and urgently needed, but the values that underpin it – integrity, compassion, altruism – can be found all around us, and have always been there in the medical profession. Indeed, while everything else in medicine has changed, they are what connects us with doctors who practised hundreds, even thousands, of years ago, often in harder times than now.

Our aim is to encourage professionalism to flourish, by ensuring the NHS is built around it. In the contracts we negotiate, in the open and engaged way in which we offer to work in partnership to reform services, and most of all in enabling integrity and compassion to be at the heart of what we do, I want this to be a good year for professionalism, and a great one for patient care.

Don’t wait to make NHS changes in 2014

By Partha Kar - 2nd January 2014 2:45 pm

You pause at landmark birthdays, don’t you? Or that’s what the world would have you believe. At 40, stepping into middle age, is it time to slow down? As I sit here and reflect over the past few years, the answer to that becomes obvious.

So what has time taught me? I became a consultant in 2008 and, even in my wildest dreams, I couldn’t have imagined the distance that has been travelled and the experiences gained since then.

My personal learning points? Here we go…

1.) Empathy and evangelism

The NHS has had a major cathartic moment via Mid staffs, Francis report etc and has brought forward a degree of empathy on social media rarely seen before. Empathy is something we learn gradually about but you know what - it is damn tiring to do so 24/7.

Somewhere in the middle, lots have forgotten that healthcare professionals, as anyone else, are human beings…same foibles, same passion, same problems. Does that make them a less empathetic person? No, it  doesn’t.

2.) Power and influence

As one of my good friends recently said, the present currency is not power, but influence. And my observation? Official high ranking posts are now subject to so many rules, regulations and targets that good people end up doing things and getting involved with issues they would never do otherwise. I know so because they are different individuals when they are free from the trappings of such roles. And that’s not for me - change can be brought by influence and that is where it’s at.

Some targets, however, are simply meaningless and continue because of political expediency - and they, unfortunately, are beyond our influence.

3.) Money and practicality

There is a surfeit of folks willing to work differently. At the end of the day, the money has run out. Yes, I know that Clive Peedell will tell you that not having transactional costs would save NHS money, and how not having Trident would help the NHS. But, the reality? That’s beyond the realm of control for folks like us.

They are political issues which at the moment don’t look like getting resolved. So let me put this bluntly, the system has, as things stand, run out of capacity. So an honest dialogue with patients is where it’s at. When there isn’t a service available, it isn’t because the doctors/nurses don’t care or the CCGs are evil. They simply don’t have enough money. Everyone knows it, we just don’t know what to do about it any more.

4.) Leaders and credentials

An explosion of leaders seems to have happened, unfortunately without the supporting credentials. Lots of talk, lots of meetings, lots of lectures, opinions…but dig deep, and these leaders have just been moved around from one failing project to another.

A good speaker and some funky Power Point slides does not make a good leader I am afraid; I recall going to a meeting a few years back on 7-day working when a consultant stood up as a lecturer and passionately put the case for 7-day senior cover. Problem? I was his house officer once upon a time and his contribution to the wards was negligible.

I am very fortunate to be in my position. A consultant working across an acute trust and two community providers, with 80 GP surgeries. It’s been an education, building bridges, appreciating all the pressures, and you know what? There’s no course that will teach you how to develop mutual respect between primary and specialist care.

Making it happen has given us the chance to build influence and I have some big ideas - who needs national documents when you can forge your own way?

Finally, have honest conversations with patients about where things are as regards money but try and work within the system to see what can be done. Example? Patients complained about lack of diabetes input over weekends, so we worked with commissioners, and used existing best practice tariffs and - three months later - we are there.

2014 is about fighting passionately for patients, and working with like minded colleagues to effect big systematic changes but within the present financial margins. Mellow down at 40? No way, it’s time to shift up a gear.

Hospitals must change but for the right reasons

By Francesca Robinson - 17th December 2013 10:56 am

Two senior clinical academics went head-to-head with different views on what the future hospital will look like at Hospital Directions conference.

Professor Tim Evans, set out the Royal College of Physicians’ vision for hospital services structured around the needs of patients.

Professor Evans who is Vice Dean of the Faculty of Intensive Care Medicine and Lead Fellow for the RCP’s Future Hospital Commission project, said hospitals should be based around the principles of   compassionate care, accommodating the Francis report and its recommendations, and should function 24 hours-a-day seven-days-a-week with stable teams who have effective relationships with community care.

There should be a whole system of integrated care merging primary care, community care, mental health and social care with hospitals.

The RCP proposes that instead of having a specialty focus hospitals should provide an acute care hub, a medical division and a clinical coordination centre overseen by a chief of medicine who would bring together the multiple skills that are needed to accommodate the general needs of patients.

Generalists would run the wards and specialists would provide specialist advice but also spend substantial amounts of time in the community delivering specialist procedures. Specialists acting as generalists could also run wards some of the time.

“A seven-day service and compassionate care are important to our population which is suffering increasingly from co morbidity and multiple problems and an integrated whole system care is what’s needed for the future,” said Professor Evans.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, argued that the Future Hospital Commission had come up with the right conclusions but not necessarily for the right reasons.

“I don’t think that the commission really addresses the upstream challenges and the issue of variation in hospitalisation rates for a given community which can vary at least three fold in a relatively small geographical area,” he said.

Part of the argument for seven day working was the interpretation of Dr Foster data which appeared to suggest that people admitted over the weekend were more likely to die than those who were admitted during the week. However the data was collected for an entirely different purpose therefore any conclusion was based on indirect interpretation of the evidence.

Professor Baker said there was significant supporting evidence gathered from stroke units which showed that any variations in mortality could be reversed by better organisation and stronger clinical leadership.

“The bald statistics suggest that people admitted to hospital on Saturdays and Sundays have a 10% higher fatality ratio than those admitted during the week. But when examined from a population level - that is a community served by a given hospital - the actual admission rate falls at the weekend by about 25%. So for a given population the chances of dying in hospital following an emergency admission to hospital based on the Dr Foster data actually drops by 13% over a weekend,” he said.

There was a more powerful case for seven-day working based on the philosophical argument that patients’ needs should be matched with the availability of expert attention regardless of where they were and regardless of where most needs were required.

Professor Baker also criticised the RCP’s proposal that specialists should take their turn managing medical emergencies. He said this would result in relatively deskilled doctors running wards who would then have to over rely on tests, technologies and guidance – this could result in clinicians losing the power to think.

He concluded that reconfiguring services was the way forward for hospitals in the future. “If you’re going to provide the same quality of service and it’s going to be based on consultants seeing patients first and there is less money available to do it, that equation adds up to delivering care in fewer places and I don’t think there is any alternative to that.”