Yesterday I posted on published data showing wide variations in outcomes from some surgery and the Royal College of Physicians’ consultation on the future of the NHS hospital. Blog readers have brought to my attention the article in the Guardian reporting the important views of the spokesperson of the RCP Future Hospital Commission, Tim Evans.
From these comments it is clear that the RCP Commission will have some important recommendations when it reports.
Tim Evans has some very radical things to say about the nature of our hospitals and has a clear vision of where to go. The paradox is that hospitals are both very busy and underutilised. Demand for their services is increasing but the best way of meeting it would be to reduce the number of locations where the whole service pretends to be supplied.
There are three strong cases to be made for concentrating hospital services in a smaller number of buildings and institutions.
The first is the pattern of demand for hospital services in the modern world. The demand for emergency care has increased by 37% increase over 10 years. But the hospital is not open for full service 24/7. At night and at weekends the hospital provides far fewer services than it does during the day. If you are going to have an emergency it’s a good idea to have it on a Wednesday afternoon and not a Friday night.
There is a 10% higher risk of a patient dying if they are admitted over the weekend with the lack of senior doctors on duty on Saturday and Sundays.
Demand for emergency hospital care exists 24/7 but the hospital is not really fully open to meet that need. As Professor Evans says “You have seven days working in Marks and Spencer’s and John Lewis but you can’t have it in a hospital or general practice. There should be a seven day health service, absolutely unquestionably”
The second argument for the concentration of services comes from the very high overhead costs of hospitals. One of the main problems that leadership in hospitals talk about is the very high fixed costs that derive from the expensive overheads of buildings and machines. But those fixed costs are so expensive because they are little used.
Professor Evans points out how underused most hospitals actually are when compared to their overhead costs.
Given these overheads, hospitals need to work for much longer hours per week to be able to provide viable services Tim Evans points out that the overheads of a hospital are made much more expensive because over the two days a week that constitute the weekend they use so little of their capacity. Much of the hospital’s capacity is working at 20% of what could be delivered if it worked all possible hours.
The third argument for concentration is based on safety. At the moment we have a very wide variation of outcomes between different institutions because not all of them can carry out sufficient numbers of procedures. The reorganisation of stroke services in various parts of the country has made the clear case that concentration brings safety. There are many other examples that will be published over the next few months.
Professor Evans reaches some significant conclusions. Referring to the work being carried out by the RCP and the Academy of Medical Royal Colleges on how many hospitals will be needed in the future Evans added, “If the modelling showed that we could only have two thirds (of the hospitals that we have at the moment) of those then I would say “Well I’m afraid that’s the case”.”
This is radical stuff. He is correct in pointing out that the medical staff we have are too thinly spread around too many hospitals to be able to provide a safe medical environment. However to meet this problem he is not arguing for tens of thousands of new hospital doctors. He knows that these cannot be trained because the country cannot afford it.
So he will be arguing for a much smaller number of hospitals where care can be concentrated and more safely delivered around the clock.
There is a growing coalition around this argument for concentration.
NHS managers and the Confederation have been arguing for it for some time.
The Richmond Group of patient’s organisations have been arguing for it for the last two years.
The major newspapers have been gathering around this for the last few years.
Increasingly most of the Royal Colleges are getting behind this argument.
Over the next few months we will see a powerful coalition forming around this argument which will come up against a Government that will resist it every step of the way.
But Saturday’s Guardian article also contained a dissenting voice.
Dr Clare Gerada chair of the RCGP dismissed Evans ideas. They reported her as saying that offering hospital services seven days a week “will siphon off much needed money into the creation of new medical and administrative teams of people in hospitals and away from where it is really needed, on things such as more day centres, respite care for carers looking after the long term ill, befriending services and home care beds”
She then, very curiously, went on to say that GP services could not open any more than they did, typically 8 am to 7 pm on weekdays, because there are not enough family doctors to staff them.
But Professor Evans was not talking about siphoning off more money into hospital care but of concentrating services in a much smaller number of hospitals that would provide much more cost effective and safer services. Concentrating existing resources into smaller units is an argument that makes sense across a wide range of services.
I will return to how this argument could be applied to GP services in the future. For the moment it is important to note that dissenting voices from inside the Royal Colleges will undermine this coalition in favour of concentrating hospital services.