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. 2001 Dec 1;323(7324):1305.

How best to organise acute hospital services?

Models of healthcare delivery need to be compared in trials

Brian Harrison 1, David Ralphs 1
PMCID: PMC1121758  PMID: 11764754

Editor—Smith ponders how acute hospital services are best organised.1 Current proposals commend hospitals and networks serving populations of 500 0002; Smith writes that the evidence that hospitals of such size are necessary to ensure high quality care is moderate for some surgical services but unclear for medical services.

But evidence in the surgical and oncological literature shows that outcomes of malignant diseases are better when patients are looked after by specialist teams rather than generalists. Similar evidence applies to joint replacement, treatment of fractured neck of femur and urological conditions, and vascular surgery.

Medical emergencies are a large part of care in most acute general hospitals in the United Kingdom. It was to deal with these that Andy Black devised his model (described by Smith), whereby patients would be first admitted to a local small hospital that would, in effect, be an assessment arm of the big hospital.

Studies in the past 10 years across the range of medical emergencies have shown better care in terms of process and outcome for asthma,3 gastrointestinal haemorrhage,4 ischaemic heart disease,5 stroke, and rehabilitation in acutely ill elderly patients. Delay in implementing optimal management in such conditions can affect outcome.

As well as achieving better outcomes, specialist teams also achieve more precise diagnosis. In the respiratory field in our hospital, patients with chronic obstructive pulmonary disease or the hyperventilation syndrome are misdiagnosed as having asthma almost daily. If they were not transferred to the specialist team they would receive inappropriate management and unnecessary drug treatment. In the present state of health service resourcing, the appropriate range and number of specialists and specialist teams can only be provided in a reasonably large acute general hospital.

The tension between access and quality that exists in any healthcare system is aggravated when that system is seriously under-resourced. Innovative suggestions such as that of Black need to be tested in trials. Such trials need to evaluate not only clinical outcomes and access but also costs and effective use of resources.

Doctors working in hospitals expect to base their practice on published evidence from basic and clinical science. We should expect the same of planners. The NHS provides a wonderful, and underused, testbed for the evaluation of different models of healthcare delivery.

References

  • 1.Smith R. How best to organise acute hospitals services? BMJ. 2001;323:245–246. doi: 10.1136/bmj.323.7307.245. . (4 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
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BMJ. 2001 Dec 1;323(7324):1305.

Real time teleneurology can help small hospitals

Victor Patterson 1

Editor—It is good to see Smith highlighting the fact that there is no evidence that medical patients are managed any better at large teaching hospitals than in smaller hospitals.1-1

For the past three years, colleagues and I have been using real time telemedicine to provide the model proposed by Andy Black1-1 for neurology admissions to Tyrone County Hospital in Northern Ireland. This small rural hospital caters for about 60 000 patients and is 53 km from the regional neurology centre in Belfast. A series of papers has shown that this practice is feasible, acceptable, and practical for patients with neurological symptoms admitted to hospital.1-2–1-4

We have shown that most of these patients—who make up a fifth of all medical admissions1-5—can be managed perfectly adequately in their local hospital with specialist advice. Of 230 consecutive patients seen by telemedicine, only seven had to be transferred to the regional neurology unit. The ease of access to specialist care is greatly welcomed by the patients, their doctors, and their local politicians.

Even though we have carried out successful research and development to show that this system is effective and cost effective, we are still having difficulty in implementing it in the mainstream of the NHS in Northern Ireland.

References

  • 1-1.Smith R. How best to organise acute hospitals services? BMJ. 2001;323:245–246. doi: 10.1136/bmj.323.7307.245. . (4 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Craig JJ, McConville JP, Patterson VH, Wootton R. Neurological examination is possible using telemedicine. J Telemed Telecare. 1999;5:177–181. doi: 10.1258/1357633991933594. [DOI] [PubMed] [Google Scholar]
  • 1-3.Craig JJ, Russell C, Patterson VH, Wootton R. User satisfaction with real-time teleneurology. J Telemed Telecare. 1999;5:237–242. doi: 10.1258/1357633991933774. [DOI] [PubMed] [Google Scholar]
  • 1-4.Craig J, Russell C, Wootton R, Patterson V. Interactive videoconsultation is a feasible method for neurological inpatient assessment. Eur J Neurol. 2000;7:699–702. doi: 10.1046/j.1468-1331.2000.00133.x. [DOI] [PubMed] [Google Scholar]
  • 1-5.Morrow JI, Patterson VH. The neurological practice of a district general hospital. J Neurol Neurosurg Psychiatry. 1987;50:1397–1401. doi: 10.1136/jnnp.50.11.1397. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2001 Dec 1;323(7324):1305.

Kidderminster is ideal site for pilot trial

Richard T Taylor 1

Editor—Smith's editorial recognises that patients throughout England deserve a better model for acute hospital services than the one that led to the drastic downgrading of Kidderminster Hospital with the consequent loss of a parliamentary seat held by a government minister.2-1

It is not too late to improve acute emergency services for patients and their families in northwest Worcestershire and south Shropshire. Kidderminster is the ideal site for a pilot trial of Andy Black's proposals2-1; local people would welcome this. Facilities still exist, and nurses have shown their willingness to return.

But the government and the West Midlands regional office of the Department of Health have to accept, as the Royal College of Physicians and the NHS Confederation already have done,2-1 that the delivery of acute emergency services in hospitals must be rethought. Without urgent reconsideration of the Worcestershire acute services plan the destruction of these facilities at Kidderminster will start soon. The opportunity to respond to local need and to provide a national trial site without the risk of promoting strife elsewhere will then be lost.

Footnotes

Dr Taylor is chairman of Kidderminster Hospital Campaign.

References

BMJ. 2001 Dec 1;323(7324):1305.

Radical thinking already exists in Kidderminster

Brian McCloskey 1

Editor—Smith's editorial on organising acute hospital services raises important issues, but his example was ill chosen.3-1 Kidderminster Hospital is not closing but will remain open as an integral part of acute hospital services for Worcestershire; it will in fact fulfil a role similar to that which he put forward.

Within our reorganised acute services most medical admissions currently come to the main site at Worcester, but the doctors are developing daily urgent assessment and triage clinics at Kidderminster. These will run alongside an ambulatory care centre that will provide high technology diagnostic imaging facilities and extensive outpatient facilities and ambulatory surgery. The minor injuries unit already has telemedicine links to the main accident and emergency site, and an on-board telemetry link to the coronary care unit provides for thrombolysis in ambulances.

The local primary care trust is involved in developing the ambulatory care centre so that the patient pathway is integrated between primary and secondary care with a range of “step up” and “step down” options. General practitioners have already developed non-hospital options for preventing admission and for support on discharge, and they now have a general practice unit in the hospital.

The health authority, with the county council, has developed public transport links between the hospital sites for staff, patients, and visitors. This will have substantial public health benefits in improving and integrating public transport in a rural county.

These service models are part of an overall attempt to tackle the conflicting demands of modern medicine. As Smith says, there is no single solution for reconfiguring acute services, but the health authority has recognised the tension between the need for specialisation and that for local access. We planned our reconfiguration holistically to try to address this tension.

There is a large difference between the model proposed in 2001 and that proposed in 1999,3-2 let alone the BMA's earlier views on “super hospitals.”3-3,3-4 Given the time span for planning and building new hospitals, how do we achieve any logic or consistency when advice from experts shifts so rapidly?

Paradoxically for the BMA, Smith may be pointing the NHS towards greater involvement with schemes built under the private finance initiative. Faster build times (and completion on time and on budget) allied with the NHS being freed from its traditional preoccupation with “owning” buildings may give us greater flexibility to respond to changing circumstances.

Footnotes

Professor McCloskey initiated the review that led to the changes at Kidderminster Hospital.

References

  • 3-1.Smith R. How best to organise acute hospitals services? BMJ. 2001;323:245–246. doi: 10.1136/bmj.323.7307.245. . (4 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-2.Joint Consultants Committee. Organisation of acute general hospital services. London: BMA; 1999. [Google Scholar]
  • 3-3.British Medical Association; Royal College of Physicians of London; Royal College of Surgeons of England. London: RCS; 1998. Provision of acute general hospital services—consultation document. [Google Scholar]
  • 3-4.British Medical Association. Leaner and fitter. What future model of delivery for acute hospital services? London: BMA; 1997. [Google Scholar]

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