Rightsizing hospitals: Wanless revisited

The unprecedented crisis in the nation’s hospitals has brought the issue of the sustainability of modern healthcare systems when faced with incessant increases in demand to the very top of the political agenda. The combination of the legacy of the COVID-19 pandemic, together with unusually high levels of winter viral infection and demographic pressures from a rapidly ageing population, shrinking cohorts of school leavers and the fallout from Brexit in reducing the potential pool of European health workers, has produced a perfect storm.

Commentators are not short of explanations for the past critical malaise, with the focus being especially on 10 years in which funding has failed to keep pace with need and the consequent attrition to health workers’ pay and conditions and morale. Pundits have also been quick to blame the recent reduction in the numbers of hospital beds as being an obvious cause for the difficulty in admitting patients to hospitals and the shortage of care home beds for the so-called ‘blocked beds’, occupied by patients who could be discharged home. But is it really so simple or is there a more systemic explanation linked to the dominance of hospitals in our medical and popular culture?^1,2

This dominance has long roots and can be traced to the rise of medicine during the Victorian age in which the demands of the privileged for personal care from elite medical specialists, and the needs of the poor for care away from insanitary domestic conditions, initially ran in parallel through the university and voluntary hospitals on the one hand and the poor law hospitals on the other. The convergence of these two strands post World War II, with the establishment of a National Health Service (NHS), also marked the point at which separation of community-based general practice from hospital career paths became absolute. ²

With this came the unbridled domination of the hospital as the centrepiece of healthcare systems both at home and abroad, with the export of a model by western clinicians that has distorted provision globally. This has often been to the benefit of the wealthy and privileged and to the detriment of the poor who have been unable to enjoy the same access to the expensive secondary and tertiary care. The British NHS with its commitment to providing ‘equal access for equal need free at the time of use’ was supposed to address this. ³ The inherent naivety of this commitment fails to come to terms with the basic dilemma that failure to prevent ill health in the first place while offering treatments that prolong survival can only continue to increase the burden of care; this is well illustrated in the case of diabetes mellitus where successful treatment has translated the background incidence into a multiple level of prevalence.

The extensive literature on health inequalities has vividly charted the extent to which, with the best of intentions, the system we have fails to address adequately either the determinants of ill health or our responses to it, leading to the inevitable conclusion that if the practice is wrong then so is the theory. ⁴

Beginning in the 1970s, there was an increasing recognition that we may be on the wrong path with the publication of the World Health Organization (WHO) Alma Ata Declaration in 1978, which called for a reorientation of health systems towards Primary Health Care grounded in a public health framework emphasising public participation and inter-sectoral action. ⁵ The WHO strategy of Health For All By The Year 2000 and the Ottawa Charter in 1984 took this further into the need for cross-cutting policies that promote and improve health.^6,7

At the heart of these initiatives was the implication that our approach to health had been distorted not only by undue emphasis on the role of hospitals in improving population health but also the over-professionalisation of everyday maladies and the management of long-term conditions. As early as 1977, Levin and his colleagues were bemoaning the fact that governments had been ignoring the overwhelming importance of lay care by family, friends and communities. ⁸

The lack of sustainability of the projected trajectory of demand versus the costs of continuing approach was recognised when, in the UK, the then Chancellor of the Exchequer, Gordon Brown, invited the banker, Derek Wanless, to review the case for bringing the funding up to the level of comparable European countries. ⁹ In supporting the case for increased funds, Wanless and his team examined three scenarios based on: the status quo; the implementation of evidence-based practice universally across the current system; and the complete systematic transformation of the NHS into one grounded in public health and full public engagement. Only under the last scenario could he justify increased funding; with both scenarios 1 and 2, the NHS was predicted to fall over either in 20 years or more slowly. Sadly, the significant increase in funds subsequently made available those 20 years ago was appropriated into a new hospital building programme together with large pay increases for NHS staff without the transformation envisaged.

As we face into the abyss in the winter of 2022/23, there are no immediate magic nostrums for the dire situation that we find ourselves in. Belatedly, there have been recent calls for a self-care strategy and for basic healthcare lessons for pupils in schools to take the pressure off the NHS itself.^10,11 However, the dominant discourse remains as one rooted in the need for more hospital beds and clinical staff.

One of the few countries that has addressed the issue at scale has been Finland, which over 40 years ago, with its Primary Care Act drew a line in the sand when it came to the split of funding between hospital care and a primary care system rooted in public health. That system extends to the provision of extensive community-based health centre networks, including community-based specialist care and GP-led beds together with impressive initiatives in which formal demand has been reduced significantly through public education programmes. In this day of digital platforms, this is not rocket science. Nor have we properly explored the potential of peer-led support groups in the management of long-term conditions.

It is many years since we closed the mental hospitals without reinvesting in a proper system of public and community mental health with disastrous results. Our inability to learn from that experience while reducing hospital bed numbers has contributed to the present sorry pass. We will heed the call for more acute hospital beds at our peril, just further kicking the can down the road.

Our perennial reluctance to look outside the UK, other than looking west to North America for solutions, has now caught up with us and the very existence of an NHS committed to equity could be under threat if some of its perennial opponents have their way.

Any incoming government administration will need to be able to demonstrate that it really grasps the issues rather than continuing with business as usual. It is many years since the London School of Hygiene and Tropical Medicine professor of medical care, Bob Logan, enunciated his Second Law of Medical Care, namely that ‘The number of beds you have is the number of beds you need’, indicating that there is a choice in how that system is designed rather than it being an act of GOD; this complements Logan’s First Law that ‘you can’t grow potatoes in an empty bed’, implying that if you have beds they will always be filled to the detriment of a proper balance with other options. ¹²

The elements of an NHS fit for the 21st century should by now be clear. Building on the WHO work, and experiences elsewhere, we should craft a system based primarily on the localities where people live and work, with centralisation reduced to a minimum; that system should primarily be about proactive population-based prevention and the healthcare management of the health problems of an ageing population that optimises the extent to which people have control over their own health destinies rather than one constructed around the perceived priorities of health professionals. Ironically, such a system, by enabling people to work flexibly and later in life, near their own communities, may also begin to resolve some of the vexed questions about staffing shortages.

Declarations

Competing Interests

None declared.

Funding

None declared.

Ethics approval

Not applicable.

Guarantor

JA.

Contributorship

Sole author.

Provenance

Commissioned; editorial review.