The Future Hospital

The Progressive Case For Change

The Institute for Public Policy Research

This recent paper from the Institute for Public Policy Research (IPPR), which has close links with New Labour, projects the reconfiguration of NHS acute hospitals in the early part of the 21^st century. The IPPR believes that hospitals must become larger, with staffing levels sufficient to deal with complex emergencies and the demands of the European Working Time Directive. It approves the recommendations of the Royal College of Surgeons of England; this will require catchment areas of about 300,000, with at least 1,000 acute beds for each hospital. This will render many smaller district general hospitals non-viable (including most Scottish hospitals and many recently constructed PFI hospitals). The IPPR predicts that much elective care, minor injuries and outpatient services can be carried out in a range of community and primary care settings. These twin trends signal the decline and fall of the small to medium sized district general hospital. The report misleadingly states at several points in its narrative that care in smaller district general hospitals is less safe than in large hospitals, ignoring a substantial body of published evidence which shows that there is no significant relationship between case volume and mortality for NHS hospitals in England and Scotland.

Alternatives to very large hospitals which permit locations nearer the communities they serve with rapid triage and the development of managed clinical networks to allow expeditious transfer of patients requiring tertiary referral are not discussed, nor is the role of developments in NHS IT which can facilitate between-hospital consultation.

The report suggests that there are too many acute beds in English hospitals based on variations in length of stay; medical and nursing staff experience of bed shortages at times of peak demand and the concept of reserve capacity to meet surges in admissions makes this assertion questionable. The report does not refer to the 2000 National Bed Inquiry which halted bed reductions in England and recommended a modest increase in acute and intermediate care bed provision.

The report states that there has been overemphasis on acute hospital services at the expense of community and primary care services. It suggests increasing concentration on preventive medicine mediated through primary care and community health services; the report is notably vague on how this should be achieved.

Like Sherlock Holmes’ dog that didn’t bark in the night, the most singular feature of this paper is what it doesn’t mention. Financial issues receive no mention. Given the approach of relative financial famine with NHS below-inflation expenditure rises in prospect following high expenditure in real terms since 1999, this is surprising. The issues of huge expenditures on management consultants, NHS IT projects and PFI are not mentioned. PFI itself, the sole route to the construction of new hospitals under New Labour receives a single mention in the text in which, amid discussion of the need for flexibility and rapid organisational change, the wisdom of 30 year PFI contracts is tentatively questioned!

The restoration of the tariff for pricing cases treated which has brought back the internal market receives the report’s blessing by introducing competition between hospitals; Foundation Hospitals are not discussed. There is no mention in the text of the role of socio-economic factors and income disparities in determining health inequality and life expectancy; an astonishing omission.

The term “privatisation”, the cornerstone of New Labour’s “reform” agenda does not merit a single mention in the text; there are a few references to “competition” which is considered a good thing. The absence of the single most important component of the New Labour agenda for change, responsible for the “permanent revolution” in the English NHS in the last 3 or 4 years gives the paper an air of unreality. For all the achievements of the NHS under New Labour (more money, substantial increases in inpatients, day cases and out patients treated, and shorter waiting lists; all unmentioned in the paper), the main concerns of health service professionals relating to rapid privatisation are not addressed in this report. NHSCA members will learn more about the ongoing privatisation of the English NHS from the peer-reviewed papers of Allyson Pollock’s group, the columns of Private Eye (M.D. and In the Back) and most recently from the detailed report by Alex Nunns for Keep Our NHS Public. (The “Patchwork Privatisation” of our Health Service: a users’ guide).

It remains unclear for whom this paper is intended. Its studied avoidance of controversy, selective bibliography and omission of the most crucial issues of NHS policy make its usefulness for NHS professionals questionable.

MATTHEW DUNNIGAN

Senior Research Fellow, Glasgow University

Former Consultant Physician