Mark Newbold
There is broad consensus that care must shift from hospital to community in the coming years, but is there is a common understanding of what this means?
It is a shift in the model of care, not a move to a different building, that is needed. Demographic change dictates that a ‘long-term conditions’ model is now appropriate, given that most acute hospital admissions are for exacerbations of chronic illness, with or without frailty. This approach involves the active maintenance of health, so that acute flare-ups and the consequent need for urgent hospital admission are lessened. In this way wellbeing is improved and the need for in-patient capacity in hospitals is kept to a minimum.
The challenge is to organise the appropriate professionals to deliver this model of care. This matters more than the ‘type’ of employing organisation. There is a need for non-medical health and social care, and for generalist and specialist medical support.
My view is that specialist medical input, at least to diagnosis, initial assessment, and treatment planning, is essential. A lifelong condition has enormous implications, and specialist expertise ensures optimum treatment and offers the best chance of maintaining health. It is what we would want for ourselves.
Hospitals currently employ these specialists, and their teams. This could be changed, although most value working with specialist colleagues, rely on expensive diagnostic support, and have an in-patient commitment as well. However, many physician specialists now see their specialty evolving to manage patients on a ‘year-round’ basis, rather than just when they fall acutely ill. Some already do this: our cystic fibrosis service is a good example.
Specialists could work for organisations other than a hospital, but why is this change necessary? The core purpose of a hospital is to deliver specialist care, and it remains a logical home for specialists, so long as they deliver care differently. It would also eliminate the present divide between in-patient and continuing care.
The concern about hospitals taking on this role revolves around an over-focus on in-patient stays, driven by financial incentives and current culture. It is true that Tariff and Payment by Results prevent hospitals investing to reduce admission, but this can easily be changed. Cultural transformation will take longer, but many hospitals have started already, driven by recognition of the need to change emphasis, and the future of some medical specialties.
My acute trust now provides post-discharge care in the home, and an acute ambulatory medicine service to minimise admissions, as well as a range of traditional community services. We have expanded along the ‘patient pathway’ because it makes best use of our expertise and, crucially, allows us to minimise the in-patient part of the process. We have agreed a contract that incentivises us to reduce admissions, and it would now be easy to extend these services to offer patients with chronic disease, who are prone to admission, year-round care and support.
This approach responds to the population need, is minimally disruptive, creates integration of services for ‘high need’ patients, and offers a viable future for hospitals. It supports the need for bed base contraction over time, which hospitals fully understand and appreciate. It would be easy to set up local collaborative arrangements with general practice to make expert generalist care available to those patients in less need of single specialty support.
As for the buildings, they should be accessible to patients and situated in their community, as indeed many hospitals are.