Abstract
Closing a hospital always generates a public outcry, even if the evidence suggests that closure will improve services. Nicholas Timmins asks why it's so difficult
The Tory MP Kenneth Clarke used to tell a story, when health minister back in the 1980s, of meeting his Italian counterpart, who complained vigorously about the difficulty of closing hospitals, when rationalisation of health services was badly needed in his own country.
“We don't have a problem,” Ken chortled. “We just close them.” And, at the simplest level, that is clearly true. In the United Kingdom numerous hospitals have closed or merged with their neighbours over the past 40 years. The exact number is hard to pin down because of the frequency of mergers. But the number of beds has certainly decreased: back in 1948, when the NHS was founded, the UK had around 550 000 beds; today the figure is half that, at around 228 000 in 2003-4.
True, the great bulk of that reduction is due to the closure of the old mental health asylums and the geriatric “back wards,” whose patients are now in means tested care homes. And people with learning disabilities have been shifted out of hospital and into social care. Even so, there are 50 000 fewer acute beds than in 1948. It is a measure of how medicine has changed that the amount of activity in that smaller number of beds is way up: more than 15 million finished consultant episodes in 2003-4, against fewer than 4000 discharges and deaths in 1951 (all data from the Office of Health Economics Compendium of Health Statistics (www.ohecompendium.org)).
Yet everyone knows that even just reshaping hospital services, let alone actually closing a hospital, can be the most searing of experiences. Take the recent reconfiguration in Halifax and Huddersfield, Yorkshire—towns 8 km apart and covered by one NHS trust. As part of a fairly complex set of changes, Huddersfield became the centre for emergency surgery, while Halifax will become a centre for specialist paediatrics and obstetrics. As a result, a midwife led unit will open in Huddersfield and obstetric led maternity services will be centred at Halifax.
The public meetings “were horrendous, not once but three times,” said Linda Riordan, Halifax's Labour MP. Doctors and managers were “shouted at and abused,” she said. “They were accused of only doing this to keep their jobs, or to get a bonus, or of lining their own pockets at the expense of patients . . . You could see the gynaecologist by the end thinking, ‘What am I doing? I'm trying to provide the best service possible, and I am getting all this.'”
So why are hospital services so hard to reshape, even when the clinical case for doing so is powerful? One reason is that although the great bulk of healthcare transactions may take place in general practice, hospitals have long been the symbol of health care. They may be dangerous places, carrying major risks of error and hospital acquired infections, but the very name still carries the medieval connotation of a hospital as a place of safety and asylum.
Hospitals bring with them, too, a sense of territory for doctors and staff. This may be less strong now than it was, but beds, and their number, can help define status. Enoch Powell noted the difficulty, when he was a health minister in the 1960s, of closing “even the most indefensible” cottage hospitals in the face of opposition from GPs, because “there, at least, [the GP] has some beds” (Medicine and Politics, London, Pitman Medical, 1976: 35-6).
Even when changes are being driven purely on clinical grounds, it can be hard to achieve medical consensus. John Maynard Keynes noted of economists that “wherever there are five gathered in a room there will be six opinions.” Substitute doctors, and you can probably add one to that.
Human nature also tends to leave hard decisions until they have to be taken. So it is rare for big changes to take place until financial imperatives demand that what is clinically necessary be done—so closures and reconfigurations become tied up in “cuts.” The current round of reconfigurations— many of which are known to have been needed for years—is a perfect illustration of that. The same tendency to delay until the budget bites means that it is rare for the money for the alternative service to be available before the old service closes, making it harder to demonstrate that the service will improve.
Politicians' accountability for tax funded health services does not, of course, make the task any easier. The former health secretary Frank Dobson summed it up: “I am not having a blue plaque on the wall of Barts saying, ‘Founded by Henry I in 1123, closed by Frank Dobson in 1999.'”
Local newspapers and other media get more mileage from highlighting opposition than support. Local MPs—witness Hazel Blears, Labour party chairwoman, campaigning against recently approved changes to services in Manchester—find it hard to go public, even when privately convinced of the case. Kidderminster is engraved on politicians' hearts. There, in 2001, Richard Taylor, a local doctor, took the parliamentary seat from a Labour minister when the local hospital was due to lose its “blue light” accident and emergency department. That case too, however, showed how horribly things can go wrong when health authorities do a lousy job of presenting the case for change. During that election campaign it was almost impossible to find anyone in the town who did not believe that the entire hospital was closing—not just the blue light service.
Perhaps too, for understandable reasons, there is a reluctance to spell out clearly that changing technology and work patterns have made existing services unsafe—or less safe than they should be. NHS managers worry that saying this bluntly risks frightening patients and demoralising staff. So the talk is of improvement, not risk. A better, blunter, language may be needed; it is not impossible. Aneurin Bevan managed it. He would, he declared, “rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one.”