Back to the future hospitals?

Often a crucial report crystallises existing thinking and developments. If that is the case with the Royal College of Physicians’ Future Hospital Commission’s report, patients may be able to look forward to significant improvements in hospital care.

As a health service historian I am fascinated by the ‘big ideas’ that colour thinking about our health service system. The first is that of the ‘system’ itself, the way in which over 200 years hospitals have progressively given up rugged independence to act as components in a national service; this is the subject of the new edition of my book on London hospitals.

Other big ideas include that of nursing (Florence Nightingale) and the district hospital with district responsibilities (Louisa Twining 1861 & Hospital Surveys of 1942). Then there is the region, traceable to Lord Dawson in 1920 and the Nuffield Provincial Hospitals Trust in 1939, as a way of co-ordinating and organising hospitals.

Specialisation emerged as a big idea in the 19th century in the USA, and in the UK pre-eminently in London. It too was opposed by the great teaching hospitals, but the idea took over hospital policy.

The cynic who experienced the stability of the consultant and ward sister-led team in the post-war years before the massive development of specialisation and intensive treatment will see this as ‘back to the future'

Reconfiguration emerged at the instance of J O F Davies from Oxford and Professor T McKeown in 1966, leading to the Bonham-Carter Report.

This argued for effective community care and urged a review of the hospital building programme. Its concepts were developed in the reports of Lord Ara Darzi who stressed the role of primary care, and the importance of ensuring care quality; his message was ‘centralise where essential, decentralise where possible’.

The recent report of the Royal College of Physicians’ Future Hospital Commission is firmly centred on patients’ needs and on abolishing the boundary between primary and hospital care. The discovery of the patient is a relatively recent big idea.

The report’s vision is of safe, effective and compassionate care 24 /7, with continuity between hospital and the community and stable medical teams. It argues for a greater accent on the general physician, a clear consultant responsibility for patients, and their movement about a hospital only when necessary for their care.

The cynic who experienced the stability of the consultant and ward sister-led team in the post-war years before the massive development of specialisation and intensive treatment will see this as ‘back to the future’.

Historically hospital doctors, including Lords Dawson and Darzi, have often planned health services without much involvement of the true generalist, the GP. Lord Moran’s view, expressed in 1958, that GPs had “fallen off the hospital ladder” (in other words, that their ability did not match those of their colleagues in the acute sector) is not entirely passé.

Furthermore, large centres will continue to shift patients to more peripheral hospitals or into the community. Patients must continue to be moved to the specialist team best able to achieve a good outcome. There must be a compromise between stability and the need for an effective service.

The acute trusts now managing community services do so to minimise the problem of boundaries and, who knows, we may end up with an integrated system such as that of Kaiser Permanente in the US.

Integration may yet be an idea whose time has finally come.

Geoffrey Rivett is a contemporary health historian and author of the website: www.nhshistory.net. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors' own.