The end of the hospital as we know it?

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Part of Time to Think Differently

How profoundly do hospitals need to change and will there be a place for the hospital as we currently know it in the health system of the future?

I want to answer this question by reflecting on the current way in which the NHS thinks about this question in theory and acts on it in practice.

There is a growing chasm between what the NHS thinks should be done to change the hospital model and what it is actually doing on the ground.

Nearly every board or leading doctor or manager in the NHS thinks that the current model of hospital care should and will be radically different in the next decade. Most people would say that this has to happen if the NHS is not going to run out of money. So the driver for change is a powerful one. Change might take the form of:

  • developing integrated care pathways that have the bulk of the pathway outside of hospital moving some categories of outpatients and day surgery out of hospital, or
  • removing the demand for emergency beds out of the hospital.

Sometimes this is backed by the idea of developing whole new models of care; sometimes it is backed by specific restructuring of current models of care.
But all around there is talk of radical change in the way in which hospitals operate. Most hospitals agree with this theoretical vision.

If you look at the long-term vision of most hospital boards, it contains a lot of change. If you add up the commissioning intentions of clinical commissioning groups (CCGs), together they create very different models of care for England’s hospitals.

Change – very radical change – in the nature of hospitals is in the air. The problem for the NHS is that it might just stay there – in the air. For in many parts of the country the moment a CCG starts to put this into operation a very different set of motivations comes into play.

In some of the CCG authorisation sessions that I have heard about, the second or third question that the panel asks the CCG is why they aren’t more worried about the way in which their commissioning intentions might ‘destabilise’ the hospital. Under those circumstances CCGs are puzzled. They look at the commissioning intentions that have just been marked green by the panel. They will have been congratulated because they have developed radical new approaches to integrated care in the home and the community.

But the moment they actually DO something they are told they should be more worried about destabilising the hospital.

This is backed up the possible action by the hospital at the moment when any of these intentions are put into effect. Hospitals still say that if you move these clinics out of the hospital, the hospital will collapse and it will be your fault.

In some parts of the country the old strategic health authority (SHA) (now a part of a new cluster and soon to be a part of the brand new NHS Commissioning Board) will then challenge the CCG about whether they really know what they are doing in moving this work out of the hospital.

  • How would they cope if the hospital fell over?
  • What plans have they got to replace the entire hospital when this happens?

It takes a brave CCG to say ’Actually whilst of course we have an input into that, it is not our prime concern.’

The brave CCG points to the new architecture and says that luckily Monitor will have the responsibility to the public 'to ensure the continued provision of services.’ It is Monitor that will have the responsibility to look at the whole of England and see which providers are becoming unsustainable. It will be Monitor whose responsibility it will be to have plans to ensure that those services are maintained irrespective of the nature of the organisation.

My point here is that the NHS has a pretty good analysis of how the question at the top of the page should be answered. Of course it could be better; of course we probably need more fluidity in the thinking and more knowledge from other jurisdictions.

But the theoretical answer is not the problem. The problem is the practice of making the vision happen. Practically there are real road blocks placed in the way of putting that vision into reality.

Great CCGs and great provider trusts can and will get round and through those road blocks. But to radically change the hospital model in the NHS we need more than heroines and heroes.

To change something this big the whole system needs to encourage the change so that ordinary organisations can make it happen.

Professor Paul Corrigan CBE is an an Independent Consultant and Executive Coach.

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Comments

Jo Revill

Organisation
Royal College of Surgeons of England
Comment date
12 December 2012
There are few questions that are more important right now than that posed here Paul, and more ideas are badly needed around the possible new architecture.

The powerful drivers of change – the increasing number of patients with multiple conditions, the advances in technology , and most importantly of all, changing patient expectations - are factors that increasingly affect surgeons and their working practices. Solutions are about far more than hospital buildings. If we look at stroke services, we can see that one of the very early successes of the 2009 Stroke Plan was because you could have an increased use in thrombolysis, the drug treatment that breaks up blood clots to cause stroke, alongside a re-organisation that mean that once immediate care was provided at a specialised centre, patients could then be transferred to a local unit to continue recovery.

One of the problems with the NHS advocating radical change is that very often, patients’ views are not sought in any kind of constructive manner. They must be involved in building the case for change, and developing the new models of care you talk about. Are the CCGs willing to involve them and take on board what kind of hospital model they want to see?

Harry Longman

Position
Chief Executive,
Organisation
Patient Access
Comment date
12 December 2012
Powerful thinking, and thoughts which occur much more easily if your salary doesn't depend on maintaining the status quo. All of the players in the conversations above will carry on more or less as they are, and any potential losses will be vigorously guarded against. All rational adult behaviour. The arguments will always be robust and well evidenced, and will prevent any change making more than a ripple.

For something different, look outside the organisations, old or new, where people have to live on their wits, finding things to sell because they work and others will pay, not because they have a job title and an index linked pension to defend.

mark driver

Position
General Manager,
Organisation
Food Industry
Comment date
13 December 2012
Let's apply 2012 thinking and forget 1947.
Let the consumer prioritise what we want and how much we want to contribute each year.
Should the NHS be free at point of use for all for all treatments? NO.
Should the medical interaction be free but everything else paid for by the user? YES.

Richard Baum

Comment date
13 December 2012
Structural issues in the NHS will block change. As the comment above suggests, nobody depending on the existence of an organisation for their salary will work to destabalise it.
Hospitals will not pro-actively shift activity into the community because their managers need the hospital to pay their wages.
Vertical integration would help to solve this. Making organisational boundaries co-terminus with local authorities would also help with social care funding issues.

There will of course need to be specialist services delivered in different ways, but integrating local primary care, community and hospital services as a single entity will encourage the hospital part of that entity to divest unnecessary services without becoming unviable.

Chris Hopson

Position
chief executive,
Organisation
Foundation Trust Network
Comment date
13 December 2012
Shifting services to community settings without decommissioning acute facilities can mean double running costs. Removing hospital capacity cannot be done gradually because much of the cost is tied up in buildings. This is why it is important to distinguish between quality and financial objectives where service change is concerned, as some of these changes can result in increased costs in the short term.

Trusts are committed to improving service quality and patient experience through re-thinking the way that they deliver services. Some FTN members already work with partner organisations to offer chemotherapy in the home, others have succeeded in shifting services they offer into community settings, and still more wish to do so in future. In fact 78% of respondents to a recent Foundation Trust Network survey said a reconfiguration or significant transaction in their area would lead to maintained or improved patient outcomes that would not be possible if the change did not take place.

However, this must be done in a planned way. Otherwise, unfortunately, an unintended consequence may be to destabilise organisations that are effectively ‘providers of last resort’ for large numbers of NHS services. This is why it is essential that providers and commissioners work together to find ways of changing the way services are configured without triggering consequences that could damage patient interest in the long term. In some cases, where it would be appropriate to move services away from an existing provider, this must be done with a clear understanding of the long term consequences for the shape of NHS provision in an area.

Mike Smith

Position
Vice Chairman,
Organisation
Patients Association
Comment date
13 December 2012
One in 4 patients still in an acute bed would be better served in a care bed or at home with people going in. So, far better liaison between NHS and social services is essential. A care-pathway should be started from the 1st day of admission.
A properly run care bed costs a 3rd of the price of an acute bed - so 3 for the price of one. A domiciliary service even less.
Very often an elderly emergency admission, once assessed, needs care-only from the start.
With the increasing age of the population, these vital changes are likely to be pushed through by accountants rather than politicians. Politicians who don't support a local `failing' hospital lose their seats.
Patients or their relatives tell us - the Patients Association - they want to be cared for in their own hone or locality. Accountants/epidemiologists/actuaries are now - or soon will - provide the tools for the unavoidable decisions that have to be taken to `Save the NHS'.

Geoffrey Rivbett

Position
NHS historian and lead governor at an FT,
Organisation
Homerton University Hospital NHS Trust
Comment date
13 December 2012
"removing the demand for emergency beds out of the hospital"
Could Paul explain what he means? Is he suggesting emergency admissions go somewhere other than a hospital, or that having a clinical emergency is embargoed?
Geoffrey Rivett

Ed Macalister-Smith

Position
Executive coach,
Comment date
13 December 2012
Paul lays a significant challenge at the door of Monitor, to which the "brave" CCG will direct important questions about provider viability.

That sounds right in theory, and heroines / heroes for change (from both provider-land and commissioner-land) will need to be quite robust about driving the vision for a new way of doing things. They will need the support of whole systems so as to get the best outcome for patients within resources available, so potentially will need to act against the interests of individual parts of the system.

But I'm not sure that there is much sign that Monitor wants that role, or is able or willing to take action on it in any systematic way, is there? The responsibility for doing the planning will end up back with the Area Directors of the NCB, won't it?

The notion that these issues can't / shouldn't be resolved flies in the face of both the financial climate, and the inevitability of our demographics.

manjeet gill

Position
CX local govt and NED NHS,
Organisation
Lincolnshire LA and HERTS NHS
Comment date
14 December 2012
Paul, makes a strong point and one we need to debate more. This is more than Heroes, its also about leadership skills, developing more pluralistic leadership of place and outcomes. My experience of the public sector is that capability in handling complex change that is corporate or across organisations is really low to achieve this. Individual silo based leadership development will not help and we need to understand the the things that will help achieve this as well as what currently does not such as the way we develop leaders or capability. Well done Kings Fund and Paul for giving this subject its profile.

Dr Michael Crawford

Position
Consultant Medical Oncologist,
Comment date
14 December 2012
Jo Revill says “One of the problems with the NHS advocating radical change is that very often, patients’ views are not sought in any kind of constructive manner. They must be involved in building the case for change, and developing the new models of care…” A radical approach would be to restrict the consultation to those who are most obliged to depend on the NHS. The perfect focus group would include neither those with a university degree nor anyone from a household where higher-rate income tax is paid. Only then will the issues of accessibility be properly discussed.

One person who would emphatically be excluded from that group is Matthew Parris who in his column in The Times on 16th June described how he had agreed with the practice receptionist that he should bypass a consultation with the GP to take his sore wrist straight to the emergency department of the hospital for an X-ray and argued that GPs would eventually be phased out. The point is that an approach that minimises hospital use requires firstly that the out-of-hospital service exists with adequate capacity and secondly that the hearts and minds of the public are won over to making use of it as the first choice. Once this is achieved hospital services can be diminished as they are made redundant. Invest in community first, disinvest in hospitals second. You will have noticed this is not a quick way to save a few quid.

Richard Baum makes an interesting point about managers’ motivation. My impression is that a young manager who was successful in shrinking a hospital would be proud to put the achievement on a CV when applying for promotion. But Mr Baum’s point about integration hits the nail on the head. “Vertical integration would help to solve this. Making organisational boundaries co-terminous with local authorities would also help with social care funding issues… There will of course need to be specialist services delivered in different ways, but integrating local primary care, community and hospital services as a single entity will encourage the hospital part of that entity to divest unnecessary services without becoming unviable.”
Here he is, as I suspect he realises, describing the design of the NHS, including co-terminosity with local authorities that existed before Margaret Thatcher and Kenneth Clarke imposed their contrived market on the Service. Present discussions show just how damaging this was and with the purchaser/commissioner-provider relationship being at the core of NHS organisation since the damage persists.
The Dr Foster group has recently added to the body of evidence that has been quietly accumulating over the past 20 years that shows large teaching hospitals are less efficient than modestly-sized acute general hospitals. One way to increase value for money will be actually to expand some specialist services in the general hospitals to control the growth of the academic centres. My own specialty of medical oncology is an example where success is readily demonstrated and, incidentally, our patients who develop complications from treatment are per excellence those who need direct access to an inpatient service. However, it is unlikely that anyone will consider seriously the possibility of overcoming some health inequalities by reducing geographical barriers to access because that would require people to think differently.

Dr Michael Crawford

Position
Consultant Medical Oncologist,
Comment date
16 December 2012
A further point, the Scottish Governement and tthe Royal College of Physicians of Edinburgh have put out a statement on "boarding," the term North of the border for the practice of nursing patients on wards other than those appropriate for their care due to lack of capacity.

http://www.rcpe.ac.uk/documents/sg-and-rcpe-boarding-release-dec-2012.pdf

This is an increasing problem throughout the UK as hospitals' bed bases shrink faster than the need for them. It needs to be addressed in England, too.

Anonymous taxp…

Comment date
16 December 2012
To this patient and taxpayer, it sounds very much like the the author here is saying that the "brave CCG" is the one that says destabilising hospitals in this brave new fragmented world of the NHS is "not my problem".

Meanwhile, it will be the patient who suffers while you all run around in circles trying to figure out who should do what.

Paul Kerr

Position
ED consultant,
Organisation
NHS
Comment date
17 December 2012
No, but rather the end of primary care as we know it?
Referals to ED and other unscheduled care services are increasing exponentially and have been for some time and this can not continue without change
So primary care cannot continue to indulge the ever increasing (patient expectaion) for care in hospitals but must return to truly delivering some of this 24/7 or be replaced by other services

Anonymous

Position
Carer,
Comment date
28 December 2012
Care at home may be right for some patients but we should beware of assuming it is an easy solution for everyone. How many of those who blithely advocate care in the community have actually experienced it? It means your home stacked out with equipment so no room feels like home anymore. It means the patient lying in soiled bed linen waiting, perhpas all night, for the carers to arrive and hoist them so they can be changed. It means a whole host of professionals coming into your home and telling you how to organise your life, so you have no privacy anymore. It means the constant stress of waiting, often in pain, for nursing or medical care to arrive. It means symptoms going unnoticed because lay carers do not have the skill to judge when there is a problem. It means the squalor of a small bedroom becoming a toilet and a dining room at the same time.

We are fortunate in being able to afford a place in a nursing home for my husband, where carers and nurses with the proper equipment are available 24/7 and a GP is easily accessible. The NHS pays just over a £100 per week towards this nursing care and saves thousands of pounds as this is nowhere near the real cost of the regular nursing interventions which my husband needs. (and yes, I do understand the difference between nursing and social care).

Hospital may not be the right answer but neither is simply shifting the burden onto the patient and their carer.


Michael Scott

Position
Chief Executive,
Organisation
Norfolk Community Trust
Comment date
03 January 2013
As ever Paul writes cogently and compellingly , however as he well knows ' our purpose is not to describe the world but to change it '. Whilst I fully endorse the vision of this blog and the overall site - can we have more about HOW we are going to achieve this shift and more from those who have started to achieve it ?

CHRIS SAVORY

Position
INDEPENDENT CONSULTANT,
Organisation
CHJS SERVICES LIMITED
Comment date
23 January 2013
Paul Corrigan's analysis is on the button. Over time, more effort will be devoted to preventing people from requiring hospital care and there will be increasing reconfiguration of hospital services. Whether the new organisational architecture achieves this in a genuinely strategic manner is an open question. In my experience both in the NHS and local government, lack of resources coupled with increasing service demand eventually forces hard decisions to be taken. The public really want good quality care provided locally. The attachment to bricks and mortar is actually rather less important despite the hue and cry.

Susan

Comment date
30 January 2013
Interested by the comment that says ppl better in a care bed but how much nursing will be provided and who will pay?

canada goose homme

Position
canada goose homme,
Organisation
canada goose homme
Comment date
28 January 2015
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