Hospital bed in corridor

Some hospitals choose to be part of the NHS problem not the solution

By: Ben Gowland CEO NHS Nene Clinical Commissioning Group @ccginsider
Published: Monday, December 1, 2014 - 12:34 GMT Jump to Comments

A recent report says plans to keep the frail elderly out of hospital are doomed to failure. But some say it is the hospitals - institutions and people left over from a bygone era - that are the problem.

You could summarise the key points of the recent report from the "Commission on Hospital Care for Frail Older People" as follows:

• Schemes outside of hospital will not lead to savings in acute hospitals (so commissioners should not think they can reduce funding for hospitals)

• Better community and social care does not lead to less demand for acute hospital beds (so commissioners should not think they can reduce funding for hospitals)

• It is not possible to meet 2/3 of the funding gap through productivity and prevention (savings targets on hospitals are unrealistic)

• Commissioners must ensure adequate community provision (despite not reducing hospital expenditure it is still the job of commissioners to invest in community services)

• Hospitals must provide the best care for the frail elderly who are admitted (if funding is not reduced, hospitals should deliver care better than they do)

Not what you would describe as a problem solving report!  I suppose there is a place for pointing out where plans appear to be built on sand, and there are some very valid concerns raised.  The integration of health and social care is clearly not a ‘silver bullet’ for the NHS’s financial difficulties, and it takes far more than putting budgets together to make integration in practice a reality. 

That said, you would think that this self-appointed ‘influential group of health leaders’ might have been able to come up with some form of alternative, rather than simply proclaiming the status quo to be both necessary and inevitable.

The report was produced by the ‘HSJ/Serco Commission on Hospital Care for Frail Older People’, but while it calls itself a ‘commission’ it contains no one from a commissioning organisation and is chaired by the chief executive of a hospital. 

To be fair, the report is aimed more at ‘political leaders’ than commissioners, but it does fail to grasp the fundamental issue that the country is broke and can’t afford to throw money at the NHS in the way that it did in the past.  It is okay to argue that current plans (or ‘messiah concepts’ as this group call them) will not work if viable alternatives are suggested, but the report focusses on what won’t work rather than what will.  It takes a ‘not my problem’ approach to the national economic crisis, whilst presenting a thinly veiled case to protect resources for hospitals.  

The timing of the report is also significant.  It comes just as the commencement date for the Better Care Fund looms large, in which health is to transfer significant amounts of money to social care on the proviso that money is released from acute care, and at the point when commissioners are just starting contract talks with providers for next year.

This report looks very like an attempt to "re-position" the hospitals, and has the potential to be the start of something wider whereby hospitals develop their collective voice apart from the wider NHS. 

The publication of the report coincided with the Foundation Trust Network conference, and a re-naming of the Foundation Trust Network as ‘NHS Providers’.  It would seem that battle lines are beginning to be drawn. None of which is calculated to be helpful. 

The whole ethos of the 5 year forward view (5YFV) is that barriers between primary, community and secondary care need to be broken down.  The publication of this report appears to be moving in the opposite direction, with secondary care building a moat and strengthening its defences. 

I am not sure how all this will look to a neutral observer of the NHS (I am sure Joe Tibbetts will tell me in the next episode of our ‘Reality Bites’ podcast), but I doubt it is building confidence among the general population that the NHS can solve its own problems.

The problem that hospitals cause health systems in any change effort is not a new one.  Martin McKee and Judith Healy wrote about it in 2000 for the World Health Organisation in an article entitled, ‘The role of the hospital in a changing environment’.  They said,

‘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 5YFV of late 2014 talks about new models of care that integrate hospital, community and primary care services.  It requires hospitals as organisations to stop defining themselves by the hospital walls, and to turn their focus to the needs of patients right across their pathways of care.  This is hardly brand new thinking.  The Royal College of Physicians set up a Future Hospital Commission in 2013, whose recommendations included:

• 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
Keith Palmer, in his 2011 report for the Kings Fund, ‘Reconfiguring Hospital Services: Lessons from South East London’ said that hospital reconfigurations should be designed ‘along patient pathways involving specialist/tertiary hospitals, district general hospitals and primary care providers’.  And if we recall Porter and Lee’s premise in ‘The Strategy that will fix Health care’ (which we discussed in a recent article and podcast) that care needs to be organised into units responsible for the full care pathway of a patient’s condition, we now have multiple reinforcements of the outline of the models in the 5YFV. 

Hospitals need to move away from being an end in themselves, and must work to develop into organisational entities that break down the barriers between themselves and those around them.  

The problem with the HSJ/Serco report is that it does not support this way of thinking.  It doesn’t even conceive of it.  It represents yesterday's thinking stuck in the problems of today, and unable to connect with any coherent vision of the future.  Hospitals, as much as they might want to, cannot operate in splendid isolation from the rest of the system any more, and reports like this do little more than reinforce the difficulty of making the changes outlined in the 5YFV a reality.

McKee and Healy 2000 World Health Organisation paper


The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of The Information Daily, its parent company or any associated businesses.



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