Monitor has just announced that it intends to conduct an investigation into the challenges faced by small district general hospitals (DGHs) in their efforts to provide high quality and sustainable care. The regulator is asking for views from patients, providers, commissioners, healthcare professionals and other interested parties.
Even in the ‘neoliberal landscape’, there is a coherent economic argument that smaller DGHs can be more flexible, nimble and resilient in coping with the economic challenges of the NHS, as elegantly described in this recent Health Services Journal article.
District general and smaller hospitals are still populated by Doctors there with approximately at least ten years of medical training under the belt. So the idea that they are offering a second-rate service for the common medical emergencies is a fraudulent one.
Sure, it is possible to frame an argument that you can deliver a ‘mega hospital’ a bit like a “mega dairy“, but the argument that ‘big is more efficient’ is genuinely barking up the wrong tree.
For example, you will always need Doctors, nursing and allied health professional teams to deal with the ‘bread-and-butter’ of the acute medical take. This might include chest pain, acute shortness of breath (including acute severe asthma), acute exacerbation of an inflammatory bowel disease, an acute pneumonia, an acute headache, and so on.
Patients, understandably, wish to get to a local hospital without any fuss, and to be set on course for the correct treatment. They can of course be referred onto specialist centres if need be (for example an acute headache might be a bleed in the brain which requires neursurgical evacuation.)
The irony is that even people who understand markets appreciate that the market is ‘segmented’. It is impossible to address the needs of your ‘customers’, unless you understand what groups of customers desire.
The essential management steps of virtually acute medical emergencies are the same whether or not you happen to be in a district hospital or a large teaching hospital. This is because there is an acceptable standard of treatment of what clinicians would do for patient safety reasons.
For example, if you’re having an acute severe asthma attack, you are almost certainly going to have your treatment as described here on p.62 onwards of the British Thoracic Guidelines on asthma.
Monitor curiously mentions that ‘it does not wish to pre-empt the outcome’. This is extraordinary messaging. If it really really was confident about not pre-empting the outcome, why did Monitor feel to mention it at all?
We all remember David Cameron’s “no more top down reorganisations” pledge at the Royal College of Nursing Congress. The other classic is from August 2007, where Cameron promised a “bare knuckle fight” with the then Prime Minister Gordon Brown, when he launched a campaign to safeguard district hospitals.
There are reasons why one cannot be reassured about what is happening.
Whilst Lewisham won its landmark fight at the Court of Appeal against the Secretary of State for Health this week, it has just been announced that two accident and emergency (A&E) units in London are to be downgraded.
Furthermore, it is reported that fast-track hospital closures through extension of the powers of the Trust Special Administrator, have been tagged onto the Care Bill through an amendment which has received widespread opposition.
And the previous mood music hasn’t been great. For example, in their pamphlet, “Dealing with financially unstable providers”, the King’s Fund stated that:
For a competitive market to work, it is argued that there must be consequences for inefficient providers and those who do not attract patients. Again, this requires a mechanism by which providers that lose business are allowed to fail and exit the market.
The Monitor consultation therefore feels, instead, somewhat like an undertaker doing a ward round on the intensive care unit populated by critically ill patients.
Fundamentally, the problem here is one of equitable access to healthcare in the NHS.
Suppose I offered you a choice between a carton of milk in your local corner shop which you can easily walk to, or from a supermarket five miles away. You can only get to the supermarket by getting in the car. It’s the same carton of milk. Which shop do you prefer?
The issues about ‘access to medicine’ are complex. They are also hugely relevant to what sort of society we want.
It would be a grave error to ignore the views of professionals such as Dr Jonathon Tomlinson, who for example here in the London Review of Books describes a typical surgery of his.