Hospital Dr News

“Subspecialisation fragmenting inpatient care”

The new CEO of NHS England called for hospitals to consider different staffing models as the pressures on NHS services mount.

In his first major speech at the NHS Confederation annual conference, Simon Stevens questioned whether we should uncritically adopt the merge and centralise approach to NHS hospitals and services and suggested it should be “horses for courses”.

In some places, he said, mergers and traditional reconfigurations will be needed, but “let’s also allow complementary models to emerge, be tested, and adapt over time, in different communities, reflecting their different legacy care patterns and the heterogeneity of their patients”.

He also questioned the role of the trainee doctor.

“Does our historical assumption hold for all time that just about every NHS acute hospital needs a full complement of trainee doctors to keep services afloat?

“That may have been a pragmatic response during the decades when the number of hospital consultants was so constrained. But with a 76% increase in full-time-equivalent NHS hospital consultants since 2000, what if some smaller NHS hospitals decided on a different medical staffing model, more akin to that of some European hospitals?”

Stevens said subspecialisation – another product of consultant expansion – is fragmenting care for older inpatients with multi-morbidity.

He said: “One study has shown that using single condition-specific guidelines a 79-year woman with type 2 diabetes, hypertension, COPD, osteoarthritis and osteoporosis could be prescribed 19 doses of conflicting and adversely interacting medicines each day.”

He outlined a model where more general physicians – or ‘hospitalists’ – would work alongside consultant specialists – together with advanced nurse practitioners, sessional GPs, and networked staffing arrangements with neighbouring trusts.

“In our heart of hearts we know that, despite the theoretical flexibilities offered by Agenda for Change, to date much of this work has been assigned to the ‘too difficult’ box,” he added.

Stevens said he wasn’t recommending wholesale reorganisation of medical training and staffing across England, but that staffing issues should not drive the wholesale reorganisation of district general hospitals across England. “The tail should not be wagging the dog,” he said.

He cited research from Martin Gaynor, Mauro Laudicella and Carol Propper at Bristol University, which shows that despite half of acute hospitals in Englande being involved in a merger between 1997 and 2006, there was little in way of gains.

Stevens, who recently replaced David Nicholson as NHS England CEO after returning from the US where he was president of global health for private company United Health, explored three key themes in his speech to NHS leaders.

He firstly called for improvement in the sophistication of the NHS commissioning system, with a new focus on outcomes for patients and value for taxpayers; secondly, he talked about the need to accelerate the redesign of care delivery, with far greater local flexibility to meet the health and social care needs of the public; and, finally, how the NHS can actively exploiting the fundamental transformations now occurring in modern western medicine.

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