Going back to the future?

In a recent interview with The Telegraph (29 May 2014) the new chief executive of the NHS, Simon Stevens, called for an end to the mass centralisation of services and outlined the case for more care to be provided in community hospitals. This was reported by The Guardian and others as a “reversal” of current policy, but is it? Have those who have campaigned against hospitals closures or the downgrading of services won the argument? Well, not quite, as what Stevens outlined was more an evolution in policy than a reversal.

Stevens argued that the NHS must expand the provision of local services in order to meet the evolving needs of patients, particularly those who are living longer but often with multiple medical conditions. He cited Sweden, the Netherlands and the United States as countries which have pioneered community based care centred around small hospitals.

However, he was clear that he was not suggesting a return to 1950s style cottage hospitals. For all those anti-closure campaigners that is a crucial point to understand: Stevens was not advocating a return to the old model of hospital provision, but rather outlining a new and enhanced role which community hospitals could undertake.

For over a decade, there has been a trend to close or downgrade District hospitals and transfer services to fewer specialist hospitals. This has resulted in significantly improved clinical outcomes for patients who suffer heart attacks, strokes or major trauma, but it has been bitterly opposed by local communities, councillors and MPs. It has led to a system which Stevens described as “too complicated and fragmented” and which does not treat patients with “dignity and compassion”. He sees an NHS which is too complex, with too much duplication and too many gaps for patients to fall through. Part of the solution he envisages is greater support and services in communities with innovative care models.

It is clear that Stevens is keen to bolster the role of small local hospitals, but as part of a new model of care which is more integrated and patient-centric. It could see local hospitals taking over some GP services and a better alignment between community and specialist care: too often patients say they receive outstanding urgent care at a specialist hospital when they have, for example, a stroke, but they feel there is a poor handover to those providing the on-going care they need when they are discharged into the community. As Stevens put it, “if you were starting from scratch you would not design community services like that”.

One of the greatest challenges facing the NHS is avoiding older people ending up in hospital unnecessarily. It is estimated that two thirds of patients in hospitals are over retirement age and many of those admissions could have been avoided if better community based care was available. Stevens points to the 124 per cent rise in the number of people admitted to hospital for less than two days in the past 14 years as proof that the NHS has not “got it right”.

As a former adviser to two Labour health secretaries and the former PM Tony Blair, Stevens has a deep understanding of the NHS and the challenges it faces. As President of UnitedHealth Europe he also has a sound knowledge of different models of healthcare provision. His challenge is to translate his vision for the NHS into reality. That will be far from easy given the devolved nature of power and decision making within the new NHS structure in England. Aneurin Bevin, the Health Minister, Labour politician and founder of the NHS once said famously that if a bedpan dropped in a hospital corridor, the reverberations should echo in Whitehall. Those days of “command and control” have long gone if indeed they ever really existed. Stevens has articulated a community based NHS - supported by specialist hospitals - which few can argue with in principle, but redrawing professional care boundaries and associated funding arrangements will be his greatest challenge.

Kay Williamson