Is there a role for smaller hospitals in the future National Health Service?

Introduction

The NHS is challenged faced by rising demand as a consequencebecause of continued population growth, greater public expectations, anincreasingly ageing population with more complex conditions, and the rising costs of paying for that care. Inefficiencies resulting from fragmented primary, secondary and social care services highlight the need for greater coordination and continuity to improve patient outcomes at lower cost. Financial constraints can serve as a significant driver of health system review, providing impetus to modify health services delivery within the NHS to maximise value and better align with the needs of our population. Smaller acute hospitals havebeenseen as a potential starting point for the reconfiguration of ng health services in England. However, local change is not always welcome and the perceived loss of services is often met with staunch political and public opposition.Given the current austerity and need for rapid reform, is there a role for smaller hospitals in the future NHS?

Current stresses on smaller hospitals

Following the Five Year Forward View, commissioners are increasing support for primary care and integrated care models1. Recent policies have shifted in favour of more care being delivered in the community with hospitals required to reduce emergency activity.2 Alongside this there has been a squeeze on national tariffs and as a resultthus, the traditional generalist model of smaller hospitals which currently receive a significant proportion of its their funding from non-elective admissions, has become increasingly untenable. Admitting and keeping patients in hospital is expensive; the projected cost of an average patient on an NHS surgical ward amounts to more than £400 per day;where and a reduction of between two and six days per patient could save individual trusts up to £50 million each year.3Hospitals have reached breaking point as expensive stays have overburdened services where over a million A&E admissions[M1] are deemed unnecessary and almost than half of all cases require no treatment at all.4

Smaller hospitals also have to contend with a move toconsolidate some specialised services such as stroke care and complex surgery to in larger centres with greater patient numbers. Evidence suggests that tThere is a strong correlation association between the number of surgical procedures performed and the quality of patient care, emphasising the relationship between volume and outcomes. 5 Moreover, hospitals that perform a greater number of high-risk procedures have lower mortality rates than those that perform less. 6

Workforce analysis shows that smaller hospitals had higher vacancy rates than larger hospitals between 2008 and 2010. The Royal College of Physicians (RCP) anticipate a workforce crisis attributable to reduced numbers of junior doctors and shift-pattern working.7A locum bill of £2.6 billion per year suggests that not only are staffing issues dangerously inadequate but also increasinglyunaffordable.8Whilst agency and locum staffing may help to achieve adequate staffing levels, it is generally agreed that this may be at the expense of both continuity and quality of patient care.9Between 2009 and 2013, the average locum rate for smaller and smallest trusts was 2.2% and 2.6%, respectively, whereas for larger trusts it was 1.9%.10

The opportunities and risk of reconfiguration

The issues outlined above demonstrate the case for change. Smaller hospitals will now see task shifting of complex procedures to larger centres and will need to focus on community-based care. Although seemingly necessary, reconfiguration of healthcare services remains difficult mostly owing to political conflicts of political interest. There have been success stories, such as thechanges in the organisation of care for acute stroke patients in London which that exemplifyies the rewards of redesigning NHS services in pursuit of better outcomes.11 The NHS decommissioned closed down minor smaller acute stroke units and concentrated all specialist stroke carestroke care in eight of London’s largest hospitals, known as Hyper-Acute Stroke Units (HASUs). Previously, suspected stroke patients would be admitted to their local hospital with limited access to stroke specialists, necessary investigations and appropriate thrombolysis or surgical interventions. Well-resourced HASUs with highly trained multi-disciplinary teams are now able to provide high quality care in an emergency setting where ‘time is brain’.

Although public and political support for reconfiguring stroke services into HASUs across the country is, according to public consultation, currently strong12 widespread support for service reconfiguration remains limited.13 Public and political resistance to reconfiguration is therefore a significant stumbling block for the architects of the future landscape of the NHS. The NHS remains highly politicised and there are a number ofmany stakeholders involved. Reconfiguring services, often to at the perceived expense of the localhospital, evokes both a pragmatic and emotional response from the public. 14For many, the hospital is an iconic representation of the welfare state and has formed the backbone of our NHS.13 Despite evidence supporting service reconfiguration, the public are often sceptical that reforms are simply cost cutting exercises.15

Securing public engagement requires open conversation with the local population, commissioners, clinicians and managers. 16Reconfiguration of tuberculosis (TB) services in Lanarkshire in the Scottish NHS involved a stakeholder event where a voting system was implemented to determine the location for the centralised service.17 A consensus was reached which determined the hospital site of the TB service. Holding events such as this to secure public involvement and engagement can aid in overcoming obstacles related to resistance.

Evolving role of smaller hospitals in the healthcare landscape

The current financial climate necessitates that smaller hospitals adapt for sustainability. As part of achieving the NHS England Five Year Forward View, 50 vanguards sites were selected as pioneers supporting improvement and integration of services, with hopes to scale best practice across the country.18 The Five Year Forward view with its focus on community based and integrated care, presents an opportunity for visionary smaller hospitals to take a pivotal role in providing health services in the future.

Yeovil District Hospital NHS Foundation Trust, one of the vanguard sites, serves an older population, many of whom have long-term conditions and multiple morbidities. Theyhave developed the Symphony Project to meet the needs of the local population. The project brings together Somerset Clinical Commissioning Group (CCG), Dorset CCG, local GPs, adult social care from Somerset County Council and the community and mental health services provider, Somerset Partnership NHS Foundation Trust. The Symphony Project aims to deliver a new model of care based on integrated health and social care teams (including hospital specialists and GPs) to manage the care of patients with the most complex conditions within the local community.19The vanguardalso relies on an outcomes based contracting model to incentivise collaboration between all health and social care providers in the area.

Airedale Hospital NHS Foundation Trust, which is also part of the vanguard programme, has taken an innovative approach to redesign patient pathways by providing remote triage and advice via video link to patients in their homes, nursing homes and prisons. The team provides clinical consultation and inward referral to the most appropriate care setting where necessary.20 The technology is now in place in 217 care homes across the vanguard, helping residents to remain active and independent – including those with breathing problems, heart conditions and dementia – and reducing hospital admissions, A&E attendance and GP visits.20

Conclusion

The closure and reconfiguration of smaller hospitals has often been presented as a fait accompliinevitable. However, any move to do so has been met with resistance and potentially costly legal processes. The current NHS Chief Executive Officer, Simon Stevens, recently expressed his support for smaller hospitals.21 In the Five Year Forward View, smaller hospitals have an opportunity to once again be at the centre of defining patient pathways. This will require some changes in the provision of services. Gaining local public and clinician support will be crucial and small hospital leaders must be visionary. Support programmes such as the New Cavendish Group22 and New Care Models programme18 will be increasingly important in helping to ensure that smaller hospitals remain an important part of the fabric of the English NHS.

Acknowledgments: Imperial College London is grateful for support from the NW London NIHR Collaboration for Leadership in Applied Health Research & Care.

References

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[M1]Do you mean A & E attendances or hospital admissions?