Why have we forgotten the past?

February 21st 2017 and another report emerges in the press suggesting that the NHS provider sector can only be saved by closing hospitals.  True, the potential to develop centres of excellence is enhanced by having larger centres.  However, given the impossible-to-cope-with levels of bed occupancy (85% is considered the maximum sustainable, while it is currently running at 95% in many places) cutting the numbers of hospitals will only work if the numbers of beds in each is increased, and this does not appear to be on anyone’s agenda.  Despite the fact that the UK has fewer hospital beds per head of population than anywhere in Europe people seem to believe that simply speeding discharges into enhanced social care facilities, or even “step-down” hospitals, will solve the bed crisis.  Would it not also be possible, it is argued, for such facilities to take in those who do not really need an acute hospital bed, but something somewhat less acute, thus reducing the load on A&E departments?

There are several flaws in this.  First, the pressure to discharge patients in haste will not be reduced, because fewer A&E departments admitting the same numbers of patients keeps up the pressure on the front door.  Too soon a discharge leads to patients bouncing back.  Second, “Care in the community” is not cheap.  Third, it seems counter-intuitive to reduce costs by concentrating resources in larger units (otherwise known as economies of scale) while at the same time promoting the establishment of small ones.

And this is where the past comes in.  When the NHS began it assimilated voluntary hospital (which were largely broke) local authority hospitals and a vast network of small cottage hospitals.  During the 1970s and 1980s it became increasingly obvious that these small unites, with disproportionate overheads, were unaffordable.  So they were shut, or if bits such as outpatients somehow survived, the beds were close.  In my own area a thriving cottage hospital in Erith, taking GP admissions and step-down patients and even doing major surgery, fell foul of this and the need to meet ever more stringent health and safety rules.  The hip replacements done there were displaced to the district hospital.  In Greenwich, when I arrived there in 1983, the hospital stock included Greenwich District Hospital, the Brook Hospital, Woolwich, St Nicholas’ Plumstead, the Memorial Hospital on Shooters Hill, Eltham Hospital, the British Home for Mothers and Babies and the Dreadnought Seamen’s Hospital.  Well before I retired from the NHS in 2011 all were shut, and services confined to the Queen Elizabeth Hospital, which had started life as a military hospital but took civilian patients.  So eight went into one.

Why were they closed?  They were unaffordable. But all the people who agonised over those decisions are retired, or dead.  There is no institutional memory.  Instead the new ones on the block reinvent the wheel.  Medical advances have meant we can do more (which costs more), and keep people alive longer into frail old age when medical problems compound themselves.  But the basic financial rules underpinning it all have not changed.  Lots of small units accrue more costs than few, larger ones.  Domiciliary care requires more staff to cover the same workload, and travelling times make it inefficient in comparison to care in institutions.  You cannot close a hospital with 300 beds and expect to do the same amount of inpatient work in the one next door of the same size without increasing the bed numbers and staff there; keeping people out, using low-key facilities, may be just as expensive as keeping two hospitals open.

And did closing all those hospitals in Greenwich solve the financial problems?  A question to which the answer is no.  It is interesting to see the Sustainability and Transformation Plans being developed now.  My reading of most of them is

  • This is what we want to do
  • This is how much it will cost to do it
  • Oops!  We can’t

In the early 1980s when I was a clinical manager we did something very similar to an STP in one of my hospitals – except it was called a zero-based budgeting exercise.  Guess what? Exactly the same thing transpired.  The past seems to be a long-forgotten place…

Rather than fiddle with an increasingly broken system we need to grasp the nettle and go back to the drawing board.   I wonder whether, in 50 years’ time, people will wonder why it took so long to do that.  The NHS needs to cater for medicine of the 21st Century, not that of 1948.

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