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Beyond bricks and mortar

Economic and political pressures, and advances in technology, mean the case for building needs to be considered very carefully, says Brian Niven, Mott MacDonald technical director for health consulting.

There’s a lot that happens in a hospital that really shouldn’t happen in a hospital. Once people get stuck in the system, they tend to end up being there too long.

We have all read in the media about residents and politicians campaigning to save their local hospital from closure or downgrading. I’m sure that all of us would feel resentment, anger and loss to the community too, if it were to happen where we live.

Indeed, public outcry has brought about the downfall of many proposed plans by NHS commissioners over the years, creating inertia in health service planning. We’ve supported a number of high profile programmes to reconfigure provision of acute hospital services. Notable successes include the Greater Manchester ‘Healthier together’ and ‘Making it better’ programmes: changes have been agreed to the delivery of maternity, paediatrics, neonatal care, acute medicine and general surgery services. But equally, we have been involved in some which have faltered under local and national scrutiny. The stalemate cannot continue if the NHS is to continue to provide a health service fit for the 21st century.

To achieve success takes time, commitment, planning wrapped within good communication, and sincere engagement with local residents and other stakeholders. Most programmes which succeed have strong clinical leadership, and champions who are passionate about making change happen.

Business as usual won’t work

There are sound clinical planning arguments which, if articulated and presented in the right way, make a compelling case for implementing change. Not least of these are the clinical workforce challenges. Ensuring that minimum numbers of senior and junior medical staff are available seven days a week is central to maintaining patient safety and improving the quality of care.

The definition of clinical specialties is also changing and services like general surgery and general medicine are slowly being replaced by subspecialities. For example, general surgery is slowly being replaced by its subspecialties of vascular surgery, colorectal surgery, breast surgery and abdominal surgery. Why is this important? Because to achieve the clinical standards of care, each of these new subspecialties need to achieve its own minimum staffing levels and develop its own 24/7 rota.

Achieving these standards for staffing levels within each subspecialty level at every hospital site just cannot be done. Firstly, there aren’t enough trained doctors in the UK. Second, if there were enough doctors the patient workload within each subspecialty at every local hospital site would not be enough to keep these medical staff busy. The wages bill would be uneconomical, and it would impact on the specialists’ ability to maintain their skills and ensure patient safety.

Centralise, specialise

To improve patient safety and outcomes the answer for many local health leaders is to centralise services and consolidate staff in a lesser number of hospital sites.

Taking control with technology

There are of course other pressures on district general hospitals including advances in medical technology and drugs, which continue apace. We only need to look back over the last 10-15 years to appreciate their impact on how we deliver care, affecting what we can treat, and how, by who and where treatment is delivered.

There are significant transformations happening across primary, community and social care. Their integration, together with treatment and technology innovations and new working practices, could be revolutionary by enabling care outside hospital settings and diverting patients away from emergency departments.

In the longer term, the impact of public health programmes should start to kick in with more people being encouraged to look after their own wellbeing and health needs. Technology will enable patients to measure their own health and send biometric and biostatistic data to their GP. Growing our individual knowledge of health with low cost apps will become commonplace. Adaptive technology is another key growth area, as there are obvious benefits to helping people stay at home longer. As a society, we need to break out of the cycle that dictates that old and frail people enter hospital or residential and nursing accommodation.

What will all this mean for our local district general hospital? Inevitably it means change, and in some areas radical change. The future of some existing hospitals will be as larger specialist centres of excellence offering a range of acute services to a wider catchment.

The writing’s not necessarily on the wall for hospitals that do not achieve this designation. Instead of struggling to maintain patient safety across a wide range of clinical specialties, they might develop community service hubs providing integrated primary, community, social and mental health services.

Communication challenge

What is important is that the clinical arguments are sympathetically presented to local residents, in a style which is easily understood, to inform debate and discussion. The impacts of proposed plans need to be assessed, particularly when it involves travel and access to alternative sites. Patients’ concerns need to be listened to and then acted on.

In addition, the wider picture of healthcare on offer to local communities needs to be convincing and articulated in detail. If the changes implemented help people access care at home, their local GP surgery or community clinic, the opportunities and benefits need to be widely understood.

Changes in train and on the near horizon have the potential to liberate significant elements of healthcare from traditional bricks and mortar. The future of healthcare will increasingly be about promoting and providing a local, holistic, better service.

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