The future of acute care - Durrow healthcare consultancy · • that acute hospital care is undoubtedly closer to the voting public’s central nervous system than care of the elderly

A personal view: commissioned by the NHS Confederation

The future of acute careAndy Black

an NHS Confederation leading edge report

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Registered Charity no. 1090329Published by the NHS Confederation

© NHS Confederation 2006ISBN 1 85947 121 8Ref: BOK56001

Foreword 2

The traditional segmentation of the market 3

If you knew your history... 5

Back door blocked, front hall crowded 10

Towards a restructured acute hospital? 12

Alternatives to hospital admission 15

The undervalued CAM market 17

Conclusion 18

A worked example: the community medical centre 19

Contents

The imminent demise of the hospital has been arecurring theme for decades, yet hospitals are stillthriving. There are, however, some major challengesthat hospitals will have to face in coming years.While many of these stem from developments inmedicine, there are also significant pressures fromchanges in society.

The launch of Your health, your care, your say, amajor consultation on the future of communityhealth and social care services in England, also begssome important questions about what needs to beinside a hospital. Over the course of the pastcentury, the UK’s hospitals have accumulatedcontrol over many services that are typically foundoutside hospitals in other countries. ‘New’ visions forhospitals have tended to be quite rigidlyconstrained by historical or professional divisionsthat have no relationship with what patientsactually require. In particular, it is time to questionthe apparently inexorable trend towardscentralisation and specialisation, if there is to be anychance of giving reality to the rhetoric aboutshifting services closer to home.

Andy Black is a leading thinker about the futureshape of services and, in my view, one of the mostinteresting. His ideas are challenging and require are-evaluation of many of the assumptions we make.His ideas present some exciting ways in which allour services could adapt to meet shiftingexpectations, new technology and other changes inmedicine and society.

Although its focus is on hospital care, his modeleffectively removes the distinction between in-hospital and out-of-hospital care. In this visionthe hospital is part of a series of integratedcomponents embedded in their community, ratherthan the hyper-specialised, distant and isolated‘cathedral of illness’ sometimes envisaged inforecasts about the future of the hospital.

Andy Black had a management career in the NHSbetween 1973 and 1994. During this time, he helda number of positions, including running a largemetropolitan region, being a senior Governmentadviser in Whitehall, and chief executive of aLondon teaching hospital. He now runs his ownspecialist health services consultancy, Durrow Ltd.

This report does not represent the Confederation’sview but we are taking the unusual step ofpublishing a personal view of this type because,while not all Confederation members may becomfortable with these ideas, they need to bediscussed and thought about. This is a strong call to action that deserves our serious attention.

Nigel EdwardsPolicy DirectorThe NHS Confederation

Foreword

02 The future of acute care

The health sector in England can be divided intofour segments, as shown in Figure 1. The top twoquadrants represent the private sector units and thebottom two the public sector. The left siderepresents private funding and the right side public funding.

In practice, the market has been dominated fromthe bottom right quadrant: publicly funded patientsin publicly funded units. This domination has beenso absolute and endured for such an extendedperiod that it has become ingrained in the thinkingof many managers, clinicians and politicians. Eventhis Government, which has gone as far as anyother in pushing the development of the top rightquadrant (publicly funded patients in private units),began with a period in which the private sector wasseen as a port of last resort.

The migration of services from publicly provided toprivately provided is a current preoccupationbecause it is now having an impact on mainstreamNHS acute elective services. However, the pattern ofmigration is not new. Since the formation of theNHS, parts of the service have moved from thehospital or the clinic to the high street. Examplesinclude the provision of spectacles and mostaspects of vision-correction, most of dentistry and,most important of all, the provision of long-termcare of the elderly. This last aspect is looked at infurther detail on page 7.

It is not this migration to the private sector thatmakes the current juncture unique in the history ofthe NHS, but the combination of two factors:

• that acute hospital care is undoubtedly closer tothe voting public’s central nervous system thancare of the elderly

• the introduction of universal patient choice.

03

The traditional segmentation ofthe health market

The future of acute care

Figure 1. The private/publicdivide

Private patient in aprivate unit

NHS patient in a

private unit

NHS patient in an

NHS unit

Private patient in an

NHS unit

Figure 2 shows the five traditional markets for theNHS acute unit. The three green arcs coverscheduled services, the pale green denotesemergency care and blue denotes other (research,education and training). In the inner circle I havespeculated about where the locus of choice willreside. In the green zone it will be interesting to seewhether the individual patient takes over or if it willbe GP-guided choice. For emergency care it lookslikely that the PCT or some similar body will defineaccess points. Education and research will remain aspecialist contracted market, but independentproviders will move into it.

What does seem obvious is that politicians’ viewsthat ‘X per cent’ of the NHS elective cases will gointo private supply cannot survive genuine choice. A GP in Stratford-upon-Avon recently told me that if he were to give every patient achoice of elective care centres, he thought that‘about 100 per cent’ would choose the privatealternative. One can already faintly feel the groundshaking as the thundering herd of unintendedconsequences approaches.


Diagnostic services

Elec

tive

pro

ced

ure

sEd

ucatio

n, research

etc

Outpatient departments

referrals

PCT choice

GP choice

Patient choice

Emergencies

Other organisation

£

Figure 2. Classic markets for NHS acute unit

Before looking at how future NHS providers mightseek success in the new order, it is first necessary tolook backwards. It is the vogue to list current ‘driversof change’ – reports to NHS boards are rife withthem. The list (summarised below) is taken from theRoyal College of Surgeons (RCS) of London,circulated to their Reconfiguration of HealthServices committee. I find the fact that the RCS canpublish this list and the fact that they have acommittee looking at the reconfiguration of healthservices almost more interesting than its contents.

For four decades after its formation, the service theNHS gave was overwhelmingly provided by NHSemployees from publicly funded and publiclyowned assets. Funding was largely a cascade offunds from Parliament to the point of deliverythrough some form of regional, district or localbudgeting process. The allocation and spending ofthe money was an internal NHS family affair. Broadly speaking, the same family decided whatservices would be available and where they would be placed.

It was perhaps in the 1980s that thesefundamentals began to show the first signs ofbreaking up. This decade saw the introduction ofthe concepts of general management andcompulsory competitive tendering. The first markedthe germination of the managerial controlmechanism that has now achieved hegemony overthe professions; the second led (through the privatefinance initiative (PFI) and the growth of thecommercial staffing agencies) to the ‘plural market’.It also saw the emergence of the private sector as asignificant provider of NHS elective services. In 2005it is no great shock to think that a so-called NHS

05

If you knew your history …


Drivers of changePrimary drivers Secondary driversof change of change

• Payment by Results(producing verydifferent contactingarrangements)

• patient choice‘choose and book’and potential loss ofstrategic control)

• modernising medical careers(streamlined training and futurerole of consultants

• European WorkingTime Directive

• pharmaceutical and technological advancement

• deomography andepidemiology ofdisease

• independent sectorprocurement.

• foundation hospitals

• new consultants’and GPs’ contracts

• changes in privatehealthcare sector

• provision of servicesin smaller surgicalspecialties

• increasing influenceof clinical networks

• increasingspecialisation andcentralisation

• documents fromthe NationalInstitute for Healthand ClinicalExcellence andClinical OutcomesGroup

• treatment centres(NHS andindependent)

• desire of newdoctors for work–lifebalance

• more female doctors

• more doctorsworking flexibly

• introduction of non-medicallyqualified surgicalcare practitioners.

‘If you knew your history, youwouldn’t have to ask where youare coming from.’ Bob Marley

Adapted from Royal College of Surgeons of EnglandReconfiguration Working Party, 2005

hospital is effectively owned by a bank and isdependent on a percentage of nursing staffregistered with a private agency that may rise todouble figures, not to mention the PFI facilitiesmanagement subcontractors and other privatesector staff.

It is sometimes hard to remember thepsychological map of the NHS in the 1980s.Consider two widely held beliefs among NHS staff(and a sizeable proportion of the general public) ofthe time:

• if the people who cooked the meals or cleanedthe hospital corridors were not NHS employeesbut employed by a private company, then theNHS as we (and the patients) knew it was finished

• many consultants felt that they should not in anyway consider the financial costs of their clinicalactions and should not be accountable to anyonefor the way that they practised medicine.

On the second belief, Dr Martin McNicol, an earlypioneer of evidence-based practice and Presidentof the British Thoracic Society, described to me thebattles they had there as they sought to build aconsensus on guidelines for the basic treatment of asthma.

Inpatients and bed availability

Throughout these decades, the dominance of theinpatient model of care was steadily declining.Figure 3 shows the steady reduction over 50 yearsin the number of available beds per 1,000population. Even in 1973, when I started watchingthe figures, I was surprised at the willingness of NHSmanagers and clinicians alike to believe that thereduction had, or would soon, ‘bottom out’. By theturn of the millennium the NHS bed count hadreduced to approximately 2.2 acute beds per 1,000population.


All beds

Acute beds

1959 1969 1979 1989 1998

12

10

8

6

4

2

0

Per1

,000

po

pu

lati

on

Acute beds

Figure 3. Average daily available NHS beds 1959 to 1998 (England)

It was around this time that the British MedicalJournal article comparing the NHS and KaiserPermanente health systems appeared.

from BMJ Vol 24, 19 Jan 2002 p138, Table 3Letters 2002; 324: 1332; 1 June

Even correcting for error, when all the smoke andnoise is filtered out it seems obvious that Californiagets by with fewer beds than the NHS does todayat the end of the long march downwards since1945. If you visit southern California it will be veryeasy for you to see why. They do (as opposed totalking about doing) more things in communitysettings.

Care for the elderly and blocks to discharge

While acute inpatient beds were reducing, thingswere also changing in care for the elderly. In the1990s, the total number of residential placespeaked at around 500,000, with the private sectorincreasing its share of the market. (see the bottomtwo bands in Figure 4a.) Looking more closely atthe public sector share of the residential/nursinghome sector, it is apparent that during this decadethe NHS and local authorities shed around 100,000beds/places. Figure 4b shows these two bandsalone, to make the trend more visible.

07The future of acute care

600

500

400

300

200

100

‘000s

Local authority

NHS

Vol. residential

Vol. nursing

Local authority

Private nursing

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

NHS/Kaiser comparisonNHS Kaiser

Average number of primarycare doctors per office

Percentage with on-site lab,imaging, pharmacy

Average acute length of stay (days)

Adjusted for age profiles

3–5 20–40

25 95

5 3.9

644 327

Figure 4a. Elderly care market by provider, 1990–2000

The 1990s saw the beginning of the longest periodof sustained economic growth in England.Significant parts of the country began toexperience full employment. It also became

increasingly unprofitable to run a private residentialcare home for the elderly (and any other part of theeconomy that relied on poorly-paid women.)


0

20

40

60

80

100

120

140

160

180

200

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

NHS

Local authority

‘000s

Figure 4b. NHS local authority elderly care provision, 1990–2000

In Figure 5, the green line traces the year-on-yearincrease in hourly pay for women, the blue lineshows the year-on-year increase in what the publicsector (mainly local authorities) would pay for a

week’s residential care. The area between the twoshows the gap between what proprietors had topay in wages and what they received in fees.


0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

% increase in average weekly funding for residential care Increase in average hourly pay for women

%in

crea

se

Figure 5. Average pay levels outstripped funding growth forresidential care

These are averages. In the south of England thedifferential was particularly sharp. Some localauthorities in high wage areas faced the prospect ofhaving to export contracts for residential care to‘low wage’ parts of the country. I rememberworking with two acute hospitals in the same week:one in Lancashire and one in Surrey. The Surreyhospital had over 70 patients classified as ‘delayeddischarge’; in Lancashire they had three.

These issues have undoubtedly constrained thetraditional NHS discharge routes for hospitalinpatients who are in acute beds but no longerrequire acute care. Against this background, theNHS needs to be particularly careful that it doesnot, by using a hospital-centric model, over-convertthe frail elderly into candidates for long-term care.We can see from the many recent studies bychronic disease management providers that there ismajor potential to reduce inpatient demand bysubstituting community-based programmes.

If the reduction in capacity and the commercialisationof the elderly care sector made it more difficult tomove NHS inpatients out of the ‘back door’ of thehospital, there was also trouble brewing in the front hall. I am grateful to Dr Derek Bell ofEdinburgh Royal Infirmary for the following analysis.Although it relates to the hospital scene inScotland, it certainly fits the observations we havemade in England.

The graph in Figure 6 shows the number of (andreasons for) emergency admission to hospital inScotland over nearly 20 years. Two clusters emerge.Those in the upper cluster, which represents themore common reasons, not only begin higher buthave accelerated faster than the lower cluster. And the two reasons showing the fastest increaseof all are the nebulous ‘signs and symptoms’ and ‘other causes’. Underlying population morbidity isnot increasing, but more patients are presenting as emergencies.


Back door blocked, front hallcrowded

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

InjuriesOtherSymptoms and signsDigestiveHeart diseaseRespiratoryNeoplasmOther circulatoryReproductivePoisoning

Rat

ep

er10

0,00

0p

op

ula

tio

n

1981

1998

1997

1996

1995

1994

1993

1992

1991

1990

1989

1988

1987

1986

1985

1984

1983

1982

1999

Figure 6. Emergency admissions by groups of diagnosesScotland 1981 to 1999

Information and Statistics Division, NHS Scotland, January 2001

Figure 7 shows patients in eight age groups whohave had four or more admissions to hospital inthree time periods: 1985–89, 1990–94 and 1995–99.If the rate of admission within each age group wereconstant for these three periods, the three ‘year-period’

points per group would form a horizontal line. This is nearly true for the 5 to 14 age group andthere is not a great deal of change before middleage. However, the pattern shows the elderly beingrepeatedly admitted with increasing frequency.


12,000

10,000

8,000

6,000

4,000

2,000

0

0–4

5–14

15–2

4

25–4

4

45–6

4

66–7

4

75–8

4

85+

Age groups by five-year period

D a t a f o r t h r e e p e r i o d s

Per

10

0,0

00

po

pu

lati

on

1985–19891990–19941995–1999

Figure 7. Patients with four or more emergency admissions asproportion of age group in population (Scotland)

True emergency or tacticalmanoeuvres?

My personal conclusion is that the acute hospitalemergency department is increasingly being usedas an instrument to manage chronic disease. Howlong would it take any hospital to find an elderlypatient registered as an ‘emergency’ but who wasreally referred to hospital as a safety measure?

Not long ago I came across a woman who hadbeen admitted by her GP as an emergency becausethat GP cynically (and accurately) guessed that thiswould both prevent a fall and result in her broken

walking aid being replaced more quickly than anyother way. My own mother was surprised to findthat, after ringing her GP for some advice onjuggling her treatments for breathing difficulties,she was whisked off to hospital in an ambulance.She was then told that she would be in for a weekwhile they waited to ‘get her a scan’. She dischargedherself without the scan.

The ultra-aggressive policing of the four-hour A&Etarget must be making things worse. With morepatients presenting as emergencies, more are being converted to admissions. Among these, more are subsequently becoming delayed-discharge problems.

Information and Statistics Division, NHS Scotland, January 2001

Many NHS acute hospitals are working under greatpressure. Bed management and target monitoringhave become very process-intensive and areabsorbing large amounts of management andclinical resources. Not too long ago a famousteaching hospital with which I was workingconducted a survey of exactly who was in thehospital and why. The result showed that of about500 inpatients on that day about 100 were queuingfor access to diagnostics and were not acutely ill.

My first conclusion is that most NHS hospitals aretrying to retune the traditional hospital model –one hears a great deal about the ‘patient pathway’and ‘modernisation agenda’. I have to say I havebecome sceptical. At best, this is a coping strategy;at worst, it is just not working. I am unconvincedthat enforcing micro-guidance will have any lastingimpact. I am more interested in a root and branchre-examination of the way the acute hospital is structured.

It may help to analyse in a little more detail whypeople are at an acute hospital.

Who is in this hospital and why?

Put simply, all emergency patients can be dividedinto three groups:

Group oneThese people have just arrived. They were notinvited, they just turned up: they are patients inneed of assessment and a plan. These patientsarrived today or maybe last night.

Group twoThese patients have been assessed and found to bein need of acute medical care. This is the groupwith the most potential for therapeutic gain fromacute medical care and management. Thesepatients will be in their first week of stay.

Group threeThese are patients who have been in the hospitalfor more than a week. They may have been acutelyill and recovered or they may have been admittedfor other reasons. These patients are less and lesslikely to need or benefit from acute medical care,and they are more and more likely to benefit from arehabilitative regime. There is a real danger forsome that their continued stay could have anegative therapeutic value. The following wouldnot be a fanciful scenario: a crisis in social supportmet by admitting into hospital a frail but copingelderly lady results in her disorientation, furthercollapse of social support systems and a hospital-acquired infection.

Durrow Ltd have analysed the clinical activity ofmore than a dozen large NHS hospitals in the lastcouple of years, and the data fall into a clearpattern. If there were 600 inpatients, about 100would be ‘in assessment’, about 200 would bereceiving acute care and the remaining 300 wouldbe in recovery/rehabilitation or awaiting discharge.This last sector would include patients who werenever acutely ill but were admitted anyway.

So, what can be done?

A radical remix

Imagine taking all the patients (and staff ) out intothe car park one sunny day and then putting themall back in a different structure.

One new approach would be to move awaycompletely from the organisation of a hospital’sfacilities by specialty – I see the grouping ofpatients by specialty as a weakness and aconstraint, and not as a desirable objective.

Reassessing assessmentI would put all the assessment cases together andcreate a unified medical and surgical assessmentteam, led by a senior physician. I have never been afan of separate surgical and medical assessment.


Towards a restructured acute hospital?

If there are separate teams for emergency surgeryand emergency medical assessment there willalways be the potential for mismatching patients.Recourse to historical statistics will be little help –assessment of a patient with abdominal pain, forexample, is often recorded as ‘surgical’ if seen by asurgeon and ‘medical’ if seen by a physician.

One of the main objectives of this assessment unitshould be to treat the least ill patients as quickly as possible and return them home withoutadmission. This was Dr Derek Bell’s greatcontribution to the art in Edinburgh. Although itmight seem counter-intuitive to treat the least illquickest, there is logic to it – the only avoidableadmission is an avoidable admission. Dr Bell’s unit in Edinburgh was doing in two or three hours what many NHS hospitals were taking two or threedays to do. Nor were his very ill patients dying from neglect.

A very small number of emergency admissionsactually have emergency surgery (I believe thefigure is about 1 in 200). A leading physician hassaid to me, ‘If a patient really, really needs urgentsurgery then the most important thing is that theysee an emergency physician straight away. I wouldlike a cupboard in the assessment unit that saysEmergency Surgery, so that I could get them outand say: “Do that one!”‘

The acutely illThe next large group in our selection is the 200 orso patients who are acutely ill. Why divide thesepatients by specialty? Why not group them bydependency? We already do this for ‘intensively’ill patients.

The truth is that many patients have always fittedawkwardly into specialty pigeon-holes. Many ofthese patients will be elderly and will have multipleproblems. If you analyse who is in what bed youwill find that force of circumstance has resulted inpatients consistently being put in the ‘wrong’ beds. Irecently visited a relative who had had a stroke andfound her in the spinal injuries unit: both she and

the nursing staff had a tangible feeling that ‘sheshouldn’t be here’, although physically the strokeward was an exact mirror image of the spinalinjuries unit in an identical ward block not far away.Labels count. The NHS loves labels.

I will not pursue here all the arguments aboutgrouping patients of one specialty together, butbelieve me I have heard them all. It is not groupingpatients that provides the therapeutic gain ofexpert care – it is grouping and managing the skillsets of the staff. Community psychiatric nursingteams do not try to get all their patients living inthe same street.

The restWhat about the 300 patients in our sample who arenot acutely ill?

We have known since the 1970s that if youcompare all the elderly receiving care in some form– hospital, residential and nursing home or living athome with support – that clinical need is nottightly matched to their place of treatment.

Frankly, acute hospitals accommodate a lot ofinpatients who are not acutely ill. So why use anacute model of medical management? Habit.Deeply ingrained custom and habit.

My suggestion is that, after two weeks, all patientsin acute care should be automatically transferred tocare focused on rehabilitation. Many could gomuch sooner, after just a few days, and someshould go directly there. Everyone in healthcare,and others, have seen the massive impact that adynamic clinical team dedicated to activerehabilitation can have on throughput and recoveryrates. Unfortunately, most will also have seen cheapcopies that can amount to little more than‘warehousing’ the elderly.

I would physically separate these patients from theacutely ill patients and create a very differentphysical environment, one that emphasisesrecovery and wellness rather than sickness. Again,


we have known of the concept of the ‘therapeuticenvironment’ since at least the 1970s but forcomplex reasons our clinical staff do not specifysuch an environment in new facilities – theycontinually emphasise the ‘acute treatment‘environment. This is a physical environment thatsays to the patient: ‘You are (very) ill!’

Of course, acute hospitals will say that patients whoare not acutely ill should not be in acute beds and Iagree with them. The logical continuation is tomove them and halve the size of the acute hospital.The issue of chronic disease management (seepage 16) reinforces this point.

In the shorter term…

Since, in the short and medium term, non-acutepatients will be in our traditional acute hospitals,the practical approach is to recognise this andrestructure accordingly. The physical separation ofnon-acute patients allows the creation of a non-medical environment. There is also no point inproviding these patients with acute medical coverand placing them under medical management.There is no need to provide ward rounds and nightmedical cover to these patient areas. If a patient’scondition worsens, then it is more logical to movethem back into the acutely ill environment than totry to extend an acute umbrella over the wholeunit, ward or area.

There is a deeper and longer advantage to thisrestructuring. Over time, if the chronic diseasemanagement programmes begin to reshapechronic disease care, we will have a pattern of acutehospitals more suited and more appropriately sizedto deal with patients who are actually acutely ill,and the cost of this acute care will be transparentand directly funded. This contrasts with theconcealment (and under-registration) of these costsin the general bundle of outpatients, elective careand chronic disease inpatient care.


My first point was that acute hospitals needed toconsider fundamental restructuring. My second isthat those commissioning healthcare badly wantto promote alternatives to hospital admission.History shows that alternatives to hospital care arevery difficult to promote, but they highlight four main strategies:

• finding alternatives to outpatient departmentconsultation

• developing diagnostic capacity within primary care

• accelerating development of stand-aloneambulatory care centres

• introducing chronic disease managementprogrammes.

Alternatives to the outpatientdepartment

Each year there are about 70 million hospitaloutpatient attendances nationally and about 300million visits to GPs. The current average time perGP consultation is around seven minutes, whichdoctors in some other countries (and many GPshere) would think is too short. With the rise ofconsumerism, patients are taking a more active rolein the discussion of their health and treatmentdecisions. This means more time, not less, is goingto be needed. Communicating across differentlanguages and cultures also requires more time.

My point here is that GPs with special interests willnot, logistically, provide a realistic alternative toconsultant outpatient department referral. Theymay, in particular places and specialties, make asignificant contribution, but nationally the numbersdo not stack up. I would argue that the movementshould be the other way – that specialists shouldmigrate to primary care and become full partners inprimary care practices.

Diagnostic capacity in primary care

Increasing this is a surefire winner. About 40 to 45per cent of all hospital diagnostic activity is for GPs.There are high transaction costs in referring andreporting the results of referral, in addition to thecore costs of the work itself. Additionally, patientspay a high price in travel, inconvenience and stressin waiting for answers. My GP friend often needs alarge gin and tonic on getting home after anafternoon chasing results from the hospital.

We have been brainwashed into thinking that ourdiagnostic ironmongery should be working flat out, ‘sweating assets’ and all that. I like the idea ofMRI and CT scanners lying around all over thecountry with no patients in them – to me they say:‘You can have a scan today … or tomorrow.’ TheNHS is one of the least capital-intensive industriesimaginable. Most of its money goes on staff wages.

The new wave of primary care centres financed bylocal improvement finance trusts (LIFTs) shouldmake a strong contribution to increased diagnosticcapacity. These ‘super-surgeries’ will prevent patientswho need scheduled diagnostic imaging or othertests getting mixed up with the emergencypatients at the hospital. Let us hope that this willalso reduce the widespread practice of admittingpatients to hospital to gain access to diagnostics.

Independent sector treatmentcentres (ISTCs)

Stand-alone ISTCs have proliferated in recent yearsand if numbers are anything to go by, this initiativehas certainly ‘succeeded’. This is not surprising. Ifyou offer the private sector a chance to invest in anenterprise with no price or volume risks and with aguaranteed return and exit, you can certainlyexpect a response. It may be the price you have to


Alternatives to hospital admission

pay to create a market quickly. Some will say theNHS got stiffed (again). Just about nobody is beingdetached and objective. I am generally in favour ofISTCs but think that the unintended consequencesfor the legacy NHS hospitals will be more awkwardpolitically than is currently imagined.

Chronic disease management(CDM) programmes

This is surely the hot ticket for 2006. If thosecommissioning healthcare push millions of poundsinto this area you can be sure that NHS trusts, GPsand the many US-based CDM companies will enterthe arena.

I have been working with American clients in thisarea since the mid-1990s and was involved in theearly NHS studies; indeed UnitedHealth were brieflysubcontractors on the early application ofpredictive software to UK GP data. That there is akernel of great value here is clear to me. What is notso clear is how it can be introduced to the UK for alasting and constructive effect.

Leading US health policy expert Victor Villagrawrote a short and insightful objective review ofCDM in Health affairs.1 In a nutshell, he says thatdisease management in the US provided anoperational framework to manage chronic diseasebut did so in parallel with the legacy healthcaredelivery systems. He strongly advocates theintegration of CDM with primary care clinics. I think that the NHS is in danger of making thesame mistake and seeing CDM as a ‘bolt-on’additional activity.

The dichotomy between primary and secondarycare has become so habitual that we fall into thetrap of thinking that we have to work with it as agiven. In my summing up (page 18), I suggest thatwe explore hybrid formations. CDM would be oneenterprise where the contributions of individualcaseworkers, family doctors and specialists couldcombine to great therapeutic and financial effect.

For the moment, there seem to be some unrealisticaspirations among PCT executives about the speedand extent to which CDM will empty hospital beds.Their optimism is counterbalanced by layers ofcynicism and denial among acute trust executives.This is going to be a long-term game.


1‘Integrating disease management into the outpatient delivery systemduring and after managed care,’ Health affairs, W4-283, 2004

The complementary and alternative medicine(CAM) market in the US was estimated at aroundUS$27 billion in 1997. That year there were in theUS an estimated 629 million visits to CAMpractitioners, more than the number of visits toprimary care physicians. An Economist IntelligenceUnit report on the UK CAM market in the mid 1980sestimated that total turnover at that time was aboutequivalent to the annual budget of one NHS region– about 7 or 8 per cent of the NHS operationalspend at that time. Extrapolating from these figures,the value of the current UK market may be morethan £5 billion.

In 2004 I ran a check on a small market town inEngland to see what the scale of the CAM marketwas; the results are summarised below. There wereabout 40 CAM practitioners, about double thenumber of GPs. At a very crude estimate, about £2.5million of turnover was completely bypassing thelocal NHS, which was predictably strapped for cash.

The most interesting things to me about the CAMmarket are its steady growth and resilience and thefact that it is almost completely funded fromdiscretionary payments by individuals fromdisposable income.

What is the significance of this?

Consider this information in the context of the NHSchoice agenda. There is an assumption amongpoliticians that people will make choices along thelines suggested by their NHS ‘guides’. But choice isnot given, it is taken. To my mind, there isoverwhelming evidence that if people are allowedto decide where they will go for what treatment,there will be a significant vote for CAM to bebrought into the frame – another variation of the‘public pay/private provider’ segment of the market.This will result in more millions of pounds that usedto circulate inside the ‘NHS family’ moving off intothe private sector.


The undervalued CAM market

Drivers of changeComplementary and alternative medicalpractitioners in one small English town

AcupunctureAlexander techniqueAromatherapyChinese medicineChiropracticCranial reflexologyHerbalismHypnotherapyMeditationOsteopathyRelaxation therapyShiatsuAerobics venuesPilates venuesSwiss ball venuesTai chi venuesThai kickboxing venuesYoga venues

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Future success for healthcare providers in the UKmay not be a matter of manipulating the existingNHS formations, and now is a good time to exploresome new possibilities that exploit theopportunities opened up by choice and Paymentby Results.

In looking at the traditional segmentation of UKhealthcare (see page 3), I have indicated that thedomination of the scene by the public pay/publicprovider, while clearly not about to vanishovernight, faces the prospect of some shrinkage aspublic pay services are provided by privateproviders of many kinds. The domination of publicpay/public provider will lose a little ground and,unfortunately, few organisations in this sector haveany financial slack at all; indeed a number are at thelimits of financial viability already. Those lost millionsof pounds will be missed.

Here would be my list of points of departure forNHS trusts looking for a successful approach tothe future:

• hybridisation of primary and secondary careservices. This would certainly include specialistsmigrating to join partnerships of primary carephysicians, and the result would not be eitherprimary or secondary care but a true hybrid

• new approaches to emergency assessment.This means the unification of medical and surgicalteams in a single emergency team

• the use of advanced technics. Technology cansupplant the use of increasingly expensive anddifficult to source skilled humans to performsimple tasks often associated with communicationsor information management

• inclusion of commercial partners. Don’t let themoney walk out of the NHS sector: join up withprivate partners and co-venture!

• inclusion of the non-NHS ‘health economy’.The CAM sector, for example, is much biggerthan we think and it is popular with the public(see page 17)

• inclusion of ‘wellness’ facilities not just ‘illness’services. The gym, sport, spa, beauty treatmentsand a host of other activities on the borders ofhealth and leisure represent other sources of cashflow. They can also help to integrate healthservices into the local community.

• civic integration. This picks up the previous point.The NHS loves to build discrete facilities with nocrossover to the other social agencies, let alonethe high street. In one major northern city wherethe NHS is shaping up to spend over £1 billion onhospital projects, there is vague irritation that thecity council is poking its oar in and trying to assertthe importance of integrated town planning.Healthcare should be part of overall planning.


Conclusion

This is not a template, it is an extended planningdoodle – an experiment in the way the newelements I’ve described could be arranged.

The new community medical centre seeks to

provide a hub which can bring together the healthand wellness services of a typical UK town. Fromthe health service perspective it specifically blursthe line between hospital and primary care – it isneither and it is both.

A worked example: the communitymedical centre


SwimmingpoolGym and

sport

Spa Shop

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6

GP

GP

GP

GP

GP

GP

Cardiol

Paed

Phys Eld

Gastro

Lounge

Lounge

Preop Endo

Recov’y

EndoEndo

Theatre

Theatre

Theatre

Theatre

CT

Usound

XRay

MRI

Beds

BedsICU(1)

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EAU

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2

3The imagingcentre

The treatmentcentre

The wellnesscentre

The conferencecentre

1 The medicalplaza

4 The acutehospital

CafeCafe

Figure 8. How illness and wellness might be integrated in a new-style community medical centre

Some features of this model to note are:

• A full-service 24-hour/seven-day emergencyassessment and treatment unit is provided,capable of assessing patients to district generalhospital (DGH) standards. The local ambulanceservice is anchored here.

• The medical plaza provides a facility from which awide range of clinicians can practice. This includesthe functions of GPs, dentists, hospital outpatientsdepartment, as well as therapies and servicesnormally provided in private and alternativepractice.

• DGH-level diagnostics are available on-site, alongwith theatre and endoscopy intervention facilities.

• The centre also accentuates wellness. The gym,swimming pool and sports facilities bring in thehealthy as well as those recovering, to pursuetheir activities side by side. Facilities are sharedbetween the personal trainer for the healthy andthe therapist working with the cardiac rehabpatients.

The centre is a major economic and social fixture inthe community. The NHS is part of it but it is not apublic institution in feel and tempo. Many of theclinicians will be operating in private practice. Theleisure, retail and catering facilities can be providedby diverse commercial providers. Civic integration isimportant – the centre should become animportant element in the town, an impressive anduplifting space.

Further information

A more detailed paper explaining the elements ofthis concept is available on request [email protected]

For more information about the Confederation’swork in this area, please contact Nigel Edwards,Policy Director, at [email protected]



The imminent demise of the hospital has been arecurring theme for decades, yet hospitals are stillthriving. There are, however, some major challengesthat hospitals will have to face in coming years. While many of these stem from developments inmedicine, there are also significant pressures fromchanges in society.

The future of acute care has been written by Andy Black,one of the leading thinkers about the future shape ofservices. His ideas are very challenging and require a re-evaluation of many of the assumptions we make.

This report does not represent the Confederation’s view but we are publishing a personal view of this typebecause it needs to be discussed and thought about.The issues covered here are of considerable relevanceto all those involved and interested in the acute sector,and for those who care about what the future holds forthe hospital.

Further copies can be obtained from:

NHS Confederation Distribution

Tel 0870 444 5841 Fax 0870 444 5842E-mail [email protected] visit www.nhsconfed.org/publications

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The NHS Confederation’s Leading edge publications are designed to stimulate debate.

The future of acute care is the first in a series of Leading edge reports commissioned by the NHSConfederation, offering leading thinkers the opportunity to voice their views on major issuesaffecting the NHS.

Documents

The future of acute care - Durrow healthcare consultancy · • that acute hospital care is undoubtedly closer to the voting public’s central nervous system than care of the elderly