Is it the end for district general hospitals?

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Will more care at home and new 'polyclinics' spell the end of district general hospitals? Patient benefit must drive services, says Ian Gilmore, while Anthony Harrison suggests local hospitals still have a place.

Professor Ian Gilmore, President, Royal College of Physicians

I took part in a debate on the future of the district general hospital in about 1992. Malcolm Stamp, at the time chief executive of Royal Liverpool University Hospital, argued that there was no such thing as a DGH – there was no central definition of the term.

More than 15 years later neither the terminology nor the future is much clearer. But the Department of Health is promoting considerably more care in the community, including polyclinics and the stripping out of elective work to alternative providers. So the debate about the role of the DGH is timely.

Beyond definition

If we do not have a single definition of the DGH, we by and large know what we mean. It has been the backbone of secondary care for several decades. In secondary care the alternatives have been specialist hospitals and teaching hospitals. The former are sited mainly in London or other large cities and have been progressively incorporated into larger trusts. The definition of the latter has become more blurred as expanding medical student numbers have caused deans to look further for teaching and training opportunities.

I will not make a distinction between DGHs and teaching hospitals, for they both attract much urgent care from their local community, but there are issues related to size. If the DGH is under threat, most vulnerable will be the smaller ones unable to provide a full range of services and without tertiary provision such as in cardiac care and neurosurgery.

If we are to see the demise of smaller DGHs there will have to be either a large reduction in unscheduled admissions, significant reduction in lengths of stay or more alternative providers keen to enter the market. Will better continuing care in the community for long-term conditions reduce the need for admissions anticipating and preventing the exacerbations? Possibly, but this smacks of Aneurin Bevan's belief that an NHS would prevent the need for hospital care by preventing ill health. But the human condition is to die, and postponing this does not prevent ups and downs in a person's last five to 10 years.

There have been inexorable reductions in length of stay since the inception of the NHS and these have been more significant in recent years. They will get shorter still through better integration of local health and social services, but is there any prospect of further large-scale opportunities? New technologies like emergency percutaneous cardiac intervention or thrombolysis for stroke may drive care to larger DGHs and tertiary centres but patients suitable for these procedures are likely to remain only a small fraction, less than 10 per cent of myocardial infarcts and strokes. And these tertiary centres will be looking for quick transfers back to the local hospital for those not ready for home, while there is not yet much appetite among private providers for less-predictable parts of the market that make up many of the average DGH admissions.

Ambitious targets

There is a risk, however, that if elective work in, for example, surgery or gastroenterology is stripped out to independent contractors, the critical mass and expertise in the DGH might be insufficient to maintain emergency services. Will the advent of urgent care centres independent of DGHs make their A&E services surplus to requirements? Some very ambitious targets in this respect have been set in junior health minister Lord Darzi's blueprint for the health service in London. If these are to be realised, there will have to be a better understanding of how to provide access to primary care in an unscheduled way and over a wider range of hours than has been delivered to date - we await prime minister Gordon Brown's promised commitment to this with interest.

Finally, rural issues throw up considerable challenges for moving care into the community. Accessibility of services and patient convenience are important but may prove considerably less efficient than centralising services where the population density is low.

In creating a more community-oriented service model we must be careful we do not end up creating an expensive replica of traditional DGH functions while destabilising local hospitals. Service organisation must be driven by demonstrably improved patient benefit, not dogma.

The Royal College of Physicians is committed to new ways of working. We see benefits for patients through more specialists in the community and by improving the management of long-term conditions, meaning more, not less, availability of specialist care. We believe the direction of travel should no longer be for GPs to develop more specialist interests but for more specialists to move into the community, working across the primary/secondary care divide, for which good clinical engagement across primary/secondary care is essential. The market levers, particularly the tariff, must also facilitate sensible clinical networks, not hinder them.

The large DGH incorporating specialist services is here to stay. The future of smaller DGHs depends critically on their ability to complement their inpatient services with co-operative working alongside primary care so that patients get specialist advice in an environment that suits them best.

Tony Harrison, senior associate, The King's Fund

Almost before the DGH building programme was under way in the 1960s, there were second thoughts about their scale, leading to proposals for much larger hospitals than originally envisaged.

By the 1990s enthusiasts for ever-greater specialisation and the benefits of having all specialties on one site were envisaging a network of 50 or so super-hospitals for the whole of the UK.

These were never built but services were concentrated on ever-fewer sites. Specialty and small local hospitals were absorbed into larger units so that the district served by a general hospital became larger as the number and scale of its specialties grew. In the early 1990s, however, the death of the DGH was predicted on the grounds that most of their work could be done elsewhere. In fact, hospital workloads have continued to grow: no serious alternatives have emerged either to their capacity to handle emergencies or the bulk of their planned procedures.

Now the tide appears to be flowing the other way: the government has promoted the establishment of free-standing and mobile treatment centres, an investment programme for community hospitals and measures to reduce hospital emergency workload. At the same time, new roles within primary care are developing that undermine the centrality of general practice as well as extending care at home.

In addition, health minister Lord Darzi's report on London has recommended investment in a city-wide network of polyclinics in which some functions hitherto largely the preserve of hospitals would take place: these might absorb or be linked to general practice. It also recommends that the shift in hospital activities towards larger units should continue.

Complex pathways

Under this vision, the health care system is no longer a hierarchy of primary, second and tertiary sectors. Rather, it becomes a complex set of pathways and networks linking together a patient's care elements, provided by one or several sources. These episodes must take place in some physical location – how that location is described is immaterial. What is important is that these locations, whatever they are called, should provide the right balance between three key factors: quality, access and cost. Many DGHs have achieved such a balance.

Other pressure for change stems from increasing specialisation and concerns about clinical quality, the European working-time directive, and changing medical technology. The latter encourages concentration and enables dispersal. DGHs are threatened from both sides, losing some activity to larger hospitals and some to community settings.

These changes mean that in some areas the DGH, particularly where catchment areas remains low, may not represent the best balance between access, cost and quality. But this conclusion need not be universal. Geography is critical. In places where catchment areas are small, the bundle of activities found in DGHs may well have to change. But in other areas there may be no need for this.

Such hospitals may come under threat from shifts of care to community settings such as polyclinics. But the benefits and the practicality of large-scale shifts have yet to be demonstrated and it remains possible that, as in the 1990s, DGHs will exploit new technologies and procedures in order realistically to retain their share of the health budget.

The only clear conclusion possible now is that the boundaries of what we currently term hospitals will have to be flexible and open to change as new technologies and service models develop.

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