Your local hospital – under threat.

“A Local Hospital model for London” is a 62 page document from Healthcare for London (HfL), which specialises in promoting the Darzi reforms for the capital. It was published on 28th November with no publicity and is written in the usual code.

1. The Local Hospital (LH) model is based on the premise that there will be only six models of care in London ;

( A Framework for Action technical document p 15 )

2. District General Hospitals would lose:

The “minimum core services Local Hospital” would contain only:

This was the proposal in “A Framework for Action” HfL Darzi July 07 .

Finanical implications: The report discusses the financial effects of removing all of these services and finds that the “minimum core services Local Hospital” (as defined above) would operate at a huge loss, so it then goes on to discuss adding back various of the facilities, such as a 4-bedded ITU.

Then it says that the polyclinic and the elective surgery centre would be “discrete entities” separately managed, so the money they would generate would not come back to the local hospital, so it would be financially unviable anyway and could not become a “viable business” foundation trust.

3. Private ownership and a huge attack on staff are advocated as solutions. Suggestions include:

a) changes to work practices, change in skill mix, getting nurses to do doctors’ work, a great reduction in junior doctors to comply with European working tiem directives, the hospital at night team to cover the whole hospital at night from an acute assessment unit, consultant paediatricians and surgeons on networks.

b) selling off land and assets to reduce fixed costs. (PFI payments are immutable fixed costs and cannot be touched).

c) becoming part of public / private organisations variously labelled “partnerships”, “joint ventures” or “networks”, or becoming a host landlord for other services

d ) becoming part of an “integrated care organisation” (ICO). These would integrate primary and secondary care. This is the idea behind putting a polyclinic in the grounds of a hospital. It would form an integrated foundation trust business. (Still part of a publicly owned NHS to start with, this would prepare the ground for a shift to a privately owned Health Maintenance Organisation, when the government felt like tendering it out).

4. A&E sign over half a hospital:

Patients would see the A&E sign and think it was a District General Hospital as before, only to find the only doctors in the hospital were A&E doctors, physicians and obstetricians. There would not be a surgical team as part of the hospital and there would be no emergency surgery at night. For children there would be a consultant paediatrician working from a Paediatric Assessment Unit (PAU) in A&E during the day and no service at night apart from A&E doctors.

5. The assessment process of emergency patients smacks of a certain desperation to discharge patients as quickly as possible. During the day they would enter an acute assessment unit (AAU), having been seen by an A&E doctor or acute physician (seen as interchangeable) Arrangements at night are unclear. 50% of patients would be discharged within 48 hours. Any patient requiring admission would go to a “general pool of medical beds”.

6. “A general pool of medical beds”

There is no mention of coronary care, respiratory care, gastro-intestinal units, or renal units, haematology or oncology, or care of the elderly. Would the medical specialties or specialised consultant physicians exist there? Anyway there would only be a satellite lab. Would these beds be largely taken up with geriatric patients with multiple co-morbidities? (oops no, see next section.)

7. There are repeated calls to prevent patients with long-term conditions being admitted to hospital. They are to be cared for “in the community”, meaning polyclinic or home. Home care is to be provided by “clinical staff given a high degree of autonomy”. There is no mention of care by the GP, but then the plan is to abolish the GP surgery. (The only mention of GPs in the whole report is as manning the urgent care centre at the front door of the hospital, together with nurse practitioners and emergency care practitioners).

Patients with complications of COPD, CCF, heart attacks, diabetes, hypertension,etc , are not to darken the door of a hospital. The acute physicians would be working in the polyclinic to make sure this did not happen.

8. Obstetric units would continue without in-patient paediatrics, begging the question of who would resuscitate the sick newborn.

9. ITU would either not be present, or with 4 beds, would require the use of respiratory physicians as well as anaesthetists and nurse practitioners to maintain HDU +/- ITU.

10. More transfers

The report anticipates and increased need to identify sick patients and states that nurses would be trained to do this. Staff would need to be trained to stabilise, intubate and ventilate such patients ready for transfer to the acute major hospital.

Conclusion.

It has to be obvious that any hospital with an A&E sign written over the front door which did not have 24 hour surgical cover and ITU, and was taking undifferentiated patients, would be a death trap.

Patients with acute conditions could be diagnosed late and could face life-threatening trips across the capital.

This is all being proposed and instituted in the interests of shifting elective care to commercial polyclinics and ISTCs on an increasingly large scale and preparing the ground for private corporate owned hospitals.

It is designed to accelerate the advent of “joint venture” “integrated care organisations” (say a publicly owned LH with a commercially owned polyclinic and ISTC) which could in the next stage be converted into American style for-profit Health Maintenance Organisations (HMOs).

This rump local hospital has to be thrown out. The BMA has to lead an all-out fight to defend our District General Hospitals, with all the main specialties on site, alongside its campaign to save our GP’s surgeries.

If you are a BMA member please contact your division or your MSC, regional council or branch practice rep, and push to get this campaign going.

BMA Council is discussing campaigns next week.