The rise, fall, rise and fall of the community hospital; or, small is not always beautiful

Once upon a time every small town supported a cottage hospital. Usually they were funded by subscription or by company and charitable donations and bequests (it’s interesting how many War Memorial hospitals there are) and when subsumed into the NHS in 1948 they became satellite outpatient services, sometimes with inpatient beds for surgery or convalescence and often with a physiotherapy service and diagnostic facilities such as X-ray. When I worked in Bath I did satellite clinics for my various bosses in Bradford-on-Avon (excellent toys in the OT department), Frome (good cakes), Warminster, Trowbridge (sandwiches), Chippenham, Calne, Radstock and Devizes – and there were others). My own cottage hospital in the grimy South-East corner of London, near the Thames, was another such. Postcards were made of it; orthopaedic surgeons did hip replacements there; the X-ray department was in a WW2 underground hospital (the subject of another chapter); the outpatients department was a typical 1960s cottage hospital design with rabbit warrens of consulting suites and a WRVS canteen down the end. The hospital opened on its present site in 1928 and was opened by the Prince of Wales; a photograph includes the grandfather of one of my retired orthopaedic colleagues. Its activities were regularly and fully reported in the local paper (making a mockery of the partly closed modern hospital Trust Board public meetings). It raised money by raffles and fetes, where a tug-of-war competition between the local large armaments companies (and the police) was rewarded with a 16oz silver cup (Mappin & Webb) presented by Vickers in 1898, which still exists.

In the 1980s cost-cutting by rationalisation began. Small units such as ours became expensive, and just as the rise of Tesco killed the corner shop and high street by undercutting, so the cottage hospitals became uneconomic to maintain as standalone units, especially when new health and safety regulations effectively condemned the operating theatres (never mind that the infection rate was almost zero). Lengths of stay also diminished and the need for convalescence did likewise as it became apparent that rapid post-op mobilisation reduced complication rates. So Erith lost its inpatients wing to the mental health service (which later showed its ignorance by re-signing the site with large direction arrows to “Outpatience”). We watched as around the country numbers of similar units, including many I worked in around Bath, closed their doors and left their communities reliant on the big DGH miles away, thankful that at least a lack of outpatient capacity at the main hospital made our cottage hospital’s closure almost impossible. It was sad but an inevitable consequence of trying to save money.

In the late 1990s and Noughties the new New Labour government decided it would bring care closer to home. Part of this was stimulated by Fabian Society policy driven by a local MP (and GP) who wrote a pamphlet with the provocative title “Challenging the Citadel: Breaking the hospitals’ grip on the NHS”[1]. This was to involve the diversion of hospital outpatients “into the community”. Among other things it would require the building of a network of community hospitals where patients could be seen as outpatients, have tests done and receive things like physiotherapy. This new philosophy really took off, and when the government decided it was to launch an NHS Constitution the head of the NHS, David Nicholson, announced at the inaugural meeting, in 2008, how pleased he was that in his own little town (one of the Chippings, but whether it was Camden, Norton or Sodbury I cannot recall and don’t care anyway) had a brand new community hospital, and it was wonderful and the way forward.

It was all I could do not to stand up and say “HANG ON! We have spent the last 10 years closing cottage hospitals because they are uneconomic, and now you are talking about opening them all again! WHERE IS THE MONEY COMING FROM?” Actually I knew the answer to the last bit. More on that elsewhere. But the moral of this tale is that things may be nice and patient-friendly and touchy-feely, but in times of trouble Uncle Andrew thinks that financial prudence might be a Good Thing. Tesco knows best. Small may be beautiful, but not if it’s unaffordable (and it’s interesting to note that Tesco’s local “One-stop” shops charge 18% more than the supermarket price).

Our cottage hospital suddenly became the focus for a re-profiling exercise of the “move care into the community” type. Two meetings were held to brainstorm plans. These were organised by the local Primary Care Trust (PCT). It was only after the second meeting that I discovered all of this. Perhaps it was unreasonable to expect the PCT to be interested in the views of the (many) consultants who have, and still, provide an outpatient service there. After all I only worked there for 27 years. But even this initiative may come to nought, as we have a new government and PCTs are to be abolished. This raises another issue – or system fault. You can negotiate all you like but if someone changes the system, or the finance, then you have to start all over again. Old lags like me who have been around a bit have spent a lot of time trying to plan the same services with literally dozens of different people, which become tedious. If you compare some of my discussion papers from 1985 with those twenty years later it is disconcerting to realise how similar they are (except that the early ones are printed with a dot-matrix printer and the stored version is on an unreadable floppy disc, unless you happen to have an old BBC B computer knocking about…)

As a corollary, one should bear in mind that the affordability issue is stealthily rearing its head again. The Labour government of Gordon Brown created some new peers so it could boast it was a government of the talents. None of them lasted very long, but Ara Darzi, a teaching hospital surgeon, took on the total reorganisation of the NHS, general practice included, and reinvented the polyclinic concept. I remember seeing the video trailer to this where he was meandering down a hospital ward, and stopped to talk to a lady who had rheumatoid arthritis; he asked her how long she had been in, and hearing it had been for some weeks expounded at length on how such hospital stays were avoidable. Had he talked to me he would have found that such admissions are so rare that they are remembered for years; we rheumatologists hardly admit a soul these days, so it was a very bad example. I also recall that he brought over some enthusiast from Berlin to support the polyclinic cause, and remember thinking, as this chap was wheeled out all over the place, that one could not build a nationwide system based on a single example. Where were other successful models? Why were people from these not speaking also? Perhaps there weren’t any.

I was particularly upset when an extremely senior physician (indeed a College president) addressed my specialist society – of which they were also a member – and stated that Care in the Community was where we were going, and if we didn’t tag along then we would get no money so we better had. I restated my usual arguments about dilution, dispersal and the lack of evidence of cost-effectiveness[2], and suggested we should not pursue a political agenda if it was wrong. If scornful looks could kill I would not be writing this now.

I do have some sympathy (or synergy?) with the polyclinic concept. A couple were built in London, and opened to the blast of many trumpets. Two years on, and they are closing – because they are too expensive to run[3].

Told you.

 

As a PS to this, in May 2014 the new head of the NHS, Simon Stevens, was reported as suggesting the resurrection of “cottage hospitals”.  Shortly after it was denied that the report (in the “Daily Telegraph”) was correct, but I got a letter off making the above points yet again (DT, 2nd June 2014).  It has been suggested that, rather than write letters, I should take to Twitter, but thanks, David O’Reilly, I cannot think of anything worse…

[1] Stoate H, Jones B. Challenging the Citadel: Breaking the hospitals’ grip on the NHS. Fabian Ideas 620, 2006

[2] Margaret McCarthy has recently made many of the same comments about telemedicine (Show us the evidence for telehealth, BMJ 2012;344:e469)

[3] In October 2011 the GP magazine “Pulse” listed 9 centres that were either closing or being considered for closure, not the grounds of cost or service duplication

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