Future Hospital Commission – 10 years on. What's changed, what's new and what's next?

In 2013, the Royal College of Physicians (RCP) published Future hospital – Caring for medical patients.¹ This was the output of the Future Hospital Commission (FHC), established the previous year in response to growing concerns about acute hospital care that had been described as ‘hospitals on the edge’, and also in the aftermath of the Francis report on Mid Staffordshire NHS Foundation Trust.² The RCP report produced 50 recommendations and 11 key principles on how acute hospital care needed to improve for medical patients. Ten years on, many of us may feel that hospitals are ‘over the edge’ and that acute care is in a much worse predicament than when the FHC was convened and reported. We must ask ourselves: what was the impact of the FHC, and what is its relevance today?

While the FHC was led by the RCP, it brought together key clinician and patient leaders from across the healthcare system. It built on the emerging trends of medical care delivery and training, and previous work where the RCP had made major contributions, such as Shape of training³ and the Acute Medicine Task Force.⁴ The Lancet described the FHC report as ‘the most important statement about the future of British medicine for a generation’,⁵ and it has informed and influenced key policies including the NHS Long Term Plan.⁶

While the 50 recommendations were wide-ranging, they can be grouped into four main areas:

• •Organisation of acute care, and extensions outside hospital.
• •Management of multimorbidity, including the importance of general internal medicine and frailty.
• •Clinical leadership, management and approaches to improvement.
• •Patients as partners in their care, and the importance of patient experience.

Many of the hallmarks of how urgent and emergency care is currently organised or developing in the NHS were recommended in the report. The widely established model of acute medical units, same-day emergency care (SDEC), rapid frailty assessment, 7-day services, physician of the week, prioritising ward-based care and the further development of hospital at home and community-based specialist care were envisioned in the report, with the concept of the acute care hub. Recent publications in FHJ have highlighted this. In Possible futures of acute medical care in the NHS,⁷ the key attributes of a modern acute care system were described, with examples of where that is delivered and where further evaluation is required. In the March 2024 edition of the journal, a scoping review of medical SDEC⁸ emphasised the challenges in evaluating outcomes for these varying models of delivery, and the current paucity of evidence and research in this area. Hall et al described the development and spread of acute frailty assessment through the Specialised Clinical Frailty Network,⁹ and Aziz et al described the successes and challenges of implementing ‘physician of the week’ for all medical inpatients in their hospital in the Midlands.¹⁰

The Future Hospital Programme (FHP) aimed to explore whether the FHC recommendations could be implemented. The report from the eight development sites authored by Sawicka and Williams¹¹ is remarkable. Not only did the development sites deliver and develop during the programme, but the continued impact and spread of the initial work to scale in the local systems and wider is very clearly demonstrated. This was enabled by strong clinical leadership, embedded patient partnership, developing a mutually supportive network, and a systematic quality improvement approach. Each of these attributes were recommendations from the FHC, though the power and support of networks is now more widely understood for delivering improvements in services. The FHP also demonstrated how the RCP could enable these developments through supporting and developing approaches to improvement. It is a key part of our strategy.¹²

The importance of the physician as a general internist was emphasised by the FHC, and remains a hot topic today. Indeed, in the chief medical officer's annual report,¹³ he calls on the medical profession to ‘recommit to maintaining generalist skills as doctors specialise’ to meet the needs of our current and future patients. The training of physicians today is for dual accreditation in specialty and general internal medicine (GIM), but the prominence of GIM as a specialty has been slow to develop. How do we maintain those skills and practice after CCT? The debate on the balance between specialism and generalism is one that will continue and will grow in prominence; it is eloquently delivered in the debate paper by Silverton and Bright.¹⁴ As programmes for GIM as a single specialty develop, the evaluation and learning of the early stages of this are pertinent and thought-provoking.¹⁵

Medical leadership and systematic development of QI were central themes of both the FHC report and the Berwick report¹⁶ that followed the Francis report. The Chief Registrar Programme was another component of the FHP, the delivery of the concept of chief resident developed by the FHC. The growth and success of the programme and role are described by Lewis et al.¹⁷ There is no doubt that leadership and quality improvement skills are being developed early in many physicians’ careers now, though this needs continued development as we learn how to do so successfully. This is beyond what could have been imagined by the FHC. The chief of medicine role was another key recommendation of the FHC to provide clinical leadership to the operational delivery of medical care. Ben Mearns shares his experience in the role and reflects that its development, while different from that envisaged by the FHC, can be pivotal to success and improvement in a hospital, and how culture, behaviours and improvement expertise are core attributes required.¹⁸

Most importantly, how have things changed for patients, families and carers. The RCP's chair of its Patient and Carer Network gives her reflections.¹⁹ Patient partnership, respectful and inclusive care, with a focus on shared decision making were strong themes from the FHC. There is little doubt that co-production and shared decision making are embedded in more recent policy and are much more prevalent in design and delivery. The paper from the eight development sites clearly demonstrates how pivotal patients and carers were in the initial and continued local developments. The Chief Registrar Programme includes patient-delivered development sessions and the important of patient partnership in service improvement. More recent work from the RCP in partnership with NHS England on redesigning outpatient services has included co-design as a central component.²⁰

So, great progress has been made over the past 10 years in services, care and improvement approaches in line with and directly influenced by the FHC. However, the current pressures in the NHS mean that inadequate and depersonalised care continues at times. The changes in population need together with less development in other elements of care, particularly primary and social care, and the available workforce not being enough to meet this demand mean that we cannot reliably deliver the care that we want to. The Times²¹ and BMJ²² have reported their health commissions in the past 12 months, and their recommendations are important and insightful for future health and the NHS, but say little about the detail of care delivery. The FHC certainly captured and expressed the need of the moment, and there is more to be done to deliver its recommendations that remain very relevant today. Certain elements are lagging: continuity of care remains elusive, mental health needs have increased and remain segregated from whole-person care, many vulnerable people remain excluded from care, specialist care outside hospitals (although not uncommon) is not mainstream, and arguably those hospitals that may benefit most from a chief registrar don't have one.

If the Future Hospital Commission was convened today, it would likely be the Future Healthcare Commission, and gather much evidence from publications in its offspring, this journal. It would contain many of the same themes, but recognise a more diverse workforce, teams and communities, address the issues of health and healthcare inequalities, climate health, and the benefits and risks of technology.

Declaration of competing interest

Authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.