Background
In 1962 the then government proposed that patients in all parts of the country should have easy access to acute hospital care. Areas that were poorly served were to be provided with general hospitals, which would offer all but the most specialised services.
At that time, hospitals offered a very limited range of treatments. Developments in clinical knowledge and medical technology since then have radically expanded what hospitals can do and have triggered a series of changes that have transformed the way that acute care is provided.
These changes in role have been accompanied by changes in the organisational framework within which hospitals operate, designed to make them easier to manage and to operate more effectively within the wider NHS.
Drivers for change in the acute hospital sector
The main driving forces for change have been the growth of medical knowledge and the changes in diagnostic and other technologies. This has made it possible to treat a much wider range of conditions successfully and to reduce the time patients spend in hospital.
In some specialities, eg, ophthalmology, nearly all patients are now treated as day cases. As a result, the number of acute hospital beds has fallen and the number of days patients spend in hospital reduced. In addition, new and better drugs, eg, for diabetes, have made it possible for most patients to be cared for within general practice rather than in an acute hospital.
The growth in medical knowledge has also led to increasing specialisation. The typical acute hospital now has 40 or more specialties, some of which may treat only small numbers of patients per year if the hospital catchment population is relatively small. For some specialist services, eg, trauma and stroke, evidence suggests that it is beneficial to concentrate care in a smaller number of centres to achieve a greater critical mass and provide more dedicated specialist support.
The pressures to centralise some acute hospital services have been exacerbated by an EU working time directive that has reduced the hours junior doctors can work and as a result made it harder for smaller hospitals to maintain 24-hour medical cover. Concerns about patient safety have also led to closures of small units. As a consequence the number of hospitals providing a comprehensive range of acute services has reduced, and some small acute hospitals have closed.
Governance
In the 1990s the Conservative government introduced the purchaser/provider split. Responsibility for the provision of hospital services was handed over to semi-independent trusts, to operate in what was then expected to be an NHS internal market. Although the Labour government rejected competition in its early days in power, they retained NHS trusts.
In 2003, the Labour government created a new form of public benefit corporation – the foundation trust – with greater management autonomy, in line with its overall policy of passing power from the centre to localities.
Foundation trusts enjoy freedom from direction by the Secretary of State; they can employ staff on their own terms and have more scope for raising capital than their predecessors so are expected to be more innovative. Initial granting of foundation trust status and subsequent monitoring of their performance is the responsibility of a regulator, Monitor. Like NHS trusts, however, they are inspected by the Care Quality Commission.The first foundation trusts were established in 2004.
In addition, the previous government promoted the establishment of freestanding, independent treatment centres provided through the private sector, as part of its drive to reduce waiting times and increase plurality of provision. The coalition government is committed to greater involvement of independent providers.
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