NHS England Chief Executive Simon Stevens issued his challenge to rethink the role of the hospital in more imaginative ways after this week’s Nuffield Trust’s conference on the future of the hospital was already in the diary.
There were some clear lessons from our audience of hospital leaders – many on the theme that simple answers of hot-cold splits (separating emergency from elective care), centralisation, mergers etc are not working. I took away a number of lessons:
Decisions need to be made about where to focus: smaller hospitals are thinking about reducing the number of service lines they operate although they may use the site to offer a base for visiting services.
Even where there is significant change the large majority of the patients do not need to travel. This can be further reduced by the development of innovative models for acute medicine. Dartford sees itself as providing a location for a range of visiting services that will allow it to focus on its core services, providing access for its local population.
If planned work operated 12 hours a day for seven days a week, the NHS could halve the number of theatres and outpatient rooms it requires
Integrated care models can be developed by hospitals. Northumbria has developed a model that brings hospital, social care and community services together. They are starting to develop a primary care offer working with local GPs.
A new model will centralise care for the most acute patients while providing local ambulatory emergency care and specialist support to primary care. The early stages of this have managed to reduce admissions and bed days very significantly. Yeovil is repositioning the hospital as a hub in an integrated system of provision. They have learned that high cost users are not necessarily older patients.
Building networks and partnerships with other providers for the provision of more specialist services, laboratories, back office, imaging and other services is a key strategy. The lesson from hospitals in other countries is that more tiered services with escalation of more complex cases are a good way for providing access and quality for patients. There is anxiety about the competition implications of these approaches, but these seem to be overstated.
New models for acute medicine are needed – there are opportunities to change the way acute medicine operates. The Royal College of Physicians Future Hospitals Commission offers some of the most imaginative thinking in this area.
Shrinking acute work might result in growing the organisation. As hospitals rationalise some of their specialist work and change the service offer they are often simultaneously becoming the centre of a wider system of community and social care. In some cases they are also becoming a base for primary care or even a provider of these and other services.
We heard about how the new strategy for Tameside brings a wide range of health and other services on to the site which will more than compensate for the loss of some acute work. This is part of the success that Central Manchester Hospitals have had in the work reshaping services at Trafford along with a number of the other approaches listed here.
Invest in older people’s services and geriatricians that can span boundaries. The potential to reduce stays and improve the management of patients in the community is enormous. The expertise to do this and to be able to safely and quickly send patients home is vital. David Oliver talked about the success of discharge to assess models in reducing admissions to care homes. If it is not possible for patients to go home at once, extra care housing or other temporary accommodation can be used.
Estates and property are not given enough thought. Many health systems are making poor use of the large amount of the estate they own. We were told that if planned work operated 12 hours a day for seven days a week, the NHS could halve the number of theatres and outpatient rooms it requires.
Technology offers a number of opportunities– from allowing the remote reading of images, supporting self-care, providing specialist advice at a distance and in particular greatly reducing the extent to which face to face consultation is required in outpatients.
Airedale is providing telemedicine support to 18 prisons and to local nursing and residential homes. They are spreading this to other parts of the country using their infrastructure. Double digit percentage reductions in admissions and length of stay are possible for these patients.
A recurring theme was the need to have much more standardisation of processes. This creates opportunities to reduce procurement costs, redesign work in more efficient ways, provide the basis for experimentation and therefore paradoxically improve innovation.
Some of this redesign required significant reconfiguration but in most cases the process is evolutionary and the result of detailed rethinking of individual services and the systems in which they sit.
This is a job for both commissioners and providers and a strong message of the day was that providers need to be much more proactive in doing this.
Edwards N (2014) ‘The future of the hospital: some useful lessons’. Nuffield Trust comment, 13 June 2014. https://www.nuffieldtrust.org.uk/news-item/the-future-of-the-hospital-some-useful-lessons