3767247

Hospitals in England: Impact of the 1990 National Health Service ReformsAuthor(s): Anthony J. HarrisonSource: Medical Care, Vol. 35, No. 10, Supplement: Hospital Restructuring in North Americaand Europe: Patient Outcomes and Workforce Implications (Oct., 1997), pp. OS50-OS61Published by: Lippincott Williams & WilkinsStable URL: http://www.jstor.org/stable/3767247 .

Accessed: 24/04/2013 08:17

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at .http://www.jstor.org/page/info/about/policies/terms.jsp

.JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range ofcontent in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new formsof scholarship. For more information about JSTOR, please contact [email protected].

.

Lippincott Williams & Wilkins is collaborating with JSTOR to digitize, preserve and extend access to MedicalCare.

http://www.jstor.org

This content downloaded from 155.245.42.48 on Wed, 24 Apr 2013 08:17:24 AMAll use subject to JSTOR Terms and Conditions

http://www.jstor.org/action/showPublisher?publisherCode=lww

http://www.jstor.org/stable/3767247?origin=JSTOR-pdf

http://www.jstor.org/page/info/about/policies/terms.jsp


MEDICAL CARE Volume 35, Number 10, pp OS50-OS61, Supplement ?1997 Lippincott-Raven Publishers

Hospitals in England Impact of the 1990 National Health Service Reforms

ANTHONY J. HARRISON

OBJECTIVES. This article aims to describe recent changes in English hospitals, with particular reference to the impact of the National Health Service (NHS) and Community Care Act of 1990.

METHODS. Significant policies that have affected the functioning of the hospital sector of the British NHS are reviewed. Data from the NHS Depart- ment of Health are used to describe trends in utilization.

RESULTS. The NHS and Community Care Act of 1990 radically changed the financial and organizational framework within which hospitals operate. By creating separate purchasing organizations, the act opened the way for competition between hospitals. In practice, such competition has been very limited. Central directives aimed at reducing waiting times for nonurgent admissions, as well as at raising the volume of work done relative to the fi- nances available have been more significant influences. These changes, combined with rising numbers of emergency admissions, have put the physical and human resources of English hospitals under intense pressure. Admis- sions have risen, lengths of stay have fallen across all age groups, and ambulatory care has grown rapidly.

CONCLUSIONS. There is little consensus on the future direction regarding the role and structure of acute-care hospitals. There is evidence, though, that

improvements in the process and outcomes of care are possible within the current financial and organizational framework of the hospital sector.

Key words: hospital policy; hospital utilization, hospital organization; UK health reforms. (Med Care 1997;35:0S50-OS61)

The English public hospital system is cur-

rently in a phase of rapid transition with the introduction of health policy reforms that

bring market incentives to a tax-based public system of health-care financing. This article first provides historical background on the evolution of the English hospital system. It then summarizes the implications of the 1990 National Health Service (NHS) and

Community Care Act for the hospital sector.

From the King's Fund Policy Institute, London, Eng- land.

Address correspondence to: Anthony J. Harrison, King's Fund Policy Institute, 11-13 Cavendish Square, London, England, WiMOAN.

Current impacts of the reforms on the inpatient arena are discussed, and potential future trends explored. Considerable attention is given to the status of efforts to monitor

quality of care and patient health outcomes.

National Health Service and the Public

Hospital System Through 1990

The English public hospital system devel-

oped out of the two systems-the voluntary and the local authority systems-that coex- isted before the establishment of the NHS.1 In 1948, Britain's NHS, a centralized, mostly public, comprehensive health-care system, was introduced and took these two systems

OS50



Vol. 35, No. 10, Supplement

into public ownership. It was not until 1962, however, that a national hospital development plan was formulated that sought to or- ganize hospital services around local districts. It was intended that each district would have a general hospital responsible for providing the bulk of acute hospital services to its local population. At the time of this system's inception, each district's catchment population was 100,000 to 150,000 people.2

The implementation of the district system led to a program of new hospital building, particularly in rapidly expanding urban areas, and to the consolidation of existing hospitals into single sites. Large numbers of maternity hospitals and "single service" institutions were closed or their services moved elsewhere. The allocation of resources across districts for these expansions, however, was strongly influenced by historical patterns. Consequently, large urban areas, where the major teaching and research institutions resided, continued to have an ample supply of services relative to other areas. It was not until 1976 that a policy of equalizing the financial resources available to hospitals according to need was established. In keeping with the decline in the urban population, which began in the early 1970s, a series of resource allocation formulas were created to promote geographic eq- uity in the distribution of resources for hospital services. Although some elements of the formulas remain contentious, the general equalization objective was uncon- troversial.

Beginning in the 1980s, a series of hospital reforms were enacted aimed at increasing their efficiency: (1) the introduction of new management structures designed to sharpen internal accountability and decision making, (2) the publication of performance indicators, and (3) the introduction of a compulsory program of tendering for ancillary services. A new management structure replaced the consensus or tripartite model that had embodied three separate hierar-

chies-medicine, nursing, and administra- tion. In this new structure, every department ultimately reported to the chief executive or general manager. Performance indicators describing the inputs and activities of hospitals were also introduced in the early 1980s, and included such items as average length of stay, annual throughput per bed, and nurse staffing per 1,000 patient-days. And finally, a program of compulsory competitive tendering for support services was imple- mented, resulting in job losses within some areas of the NHS, and is reported to have generated substantial cost savings.3

Yet despite the national framework for ownership, financing, and reform, the Eng- lish hospital system is remarkably diverse, in terms of the range of services provided and the internal organization of care delivery. The process of consolidation into single sites, which has been taking place since the creation of the NHS, has proceeded at different rates in different geographic areas, leaving a number of single specialty hospitals serving regional or national markets. In cities large enough to have more than one hospital, there may be some degree of specialization between them, eg, only one may provide pediatrics. Furthermore, the older teaching hospitals tend to provide some services over large catchment areas. Most users of hospital services receive them in their own district or, in London and other large cities, in their own or a neighboring district, traveling further for some forms of pediatric care and specialty services provided in only a small number of institutions.

Diversity is also found in the organization of care delivery-from the provision of emergency services to staffing wards- among English hospitals. A series of studies of particular specialties carried out by Robin Dowie in the 1980s4 found a large degree of variation in the way that work was organ- ized. More recent studies carried out by the Audit Commission5'6-which along with the National Audit Office is the external auditor of the NHS for nonclinical matters

OS51

HOSPITALS IN ENGLAND



MEDICAL CARE

such as the organization and management issues-confirm that diversity persists. Sur-

prisingly, there has been remarkably little

comparative study on the merits of the different patterns of care provision seen.

The 1990 Hospital Sector Reforms

The institutional framework within which

hospitals functioned was radically changed by the 1990 NHS and Community Care Act.7'8 The act fundamentally altered the roles of and relationships between the district health authorities (DHAs) and hospitals. Previously, the responsibility for both the funding and provision of hospital services belonged to approximately 190 DHAs. The responsibility for strategic management and coordination of services resided with 14

regional health authorities, each of whom received an annual budget allocation for

hospital services to be distributed among the DHAs in their region. Under the re- formed system, the DHAs assume a princi- pal purchasing role, procuring hospital services to meet the needs of their local

populations from provider organizations which compete to provide those services.9 These provider organizations consist of hos-

pital and community health services established as self-governing trusts.10 Nearly 250 trusts have a substantial acute hospital com-

ponent. These reforms have created what has been referred to as an "internal market," in which providers are permitted a degree of

competition within the framework of a pub- licly funded system, with the goal of improv-

ing efficiency.7 In addition, the 1990 act allowed general

practitioners (GPs) who met certain require- ments to become general practice fundholders, who would also receive their own budgets to purchase some forms of elective

hospital care.10 The role of GPs as purchasers has since expanded greatly both in terms of scope of their purchasing responsibilities and the numbers who have become fundholders.1112 Approximately half the popula-

tion of England receives care in fundholding practices. And as of April 1997, a number of

practices have begun piloting the purchase of all forms of hospital care.

Virtually all hospitals, acute and non- acute, psychiatric and nonpsychiatric, are now constituted as trusts, independent of the day-to-day management of the NHS. Trusts own their physical assets, contract di-

rectly with the staff they employ, have their own accounts, and maintain their own governing boards. The board of each trust con- sists of five executives and six nonexecutives

usually recruited from the local community. Financially, trusts are required to make a 6% return on their assets, and although they may borrow to finance capital investments, their ability to do so is severely circum- scribed. Managerially, trusts are largely free to determine their internal organization and clinical structures.

The language of the 1990 act stressed the

ability of district purchasers to commission services according to local needs, and to put an end to provider hegemony in dictating care practices. In fact, the new arrangements have yielded mixed results. On the one hand, purchasers have found it hard to im-

pose themselves on providers. In most service areas, DHAs lack the clinical and mana-

gerial expertise needed for their new role, even though the Department of Health has taken a number of steps to strengthen their

knowledge base.13 On the other hand, GP fundholders have been somewhat more successful in altering the way that hospitals provide services. They have persuaded some

hospital-based consultants to see patients on GP premises, and have achieved quicker turnaround times for laboratory results at

hospitals by threatening to use private firms instead. Still, according to the Audit Com- mission assessments,5'6 in most cases GP fundholders are content with the status quo, and have not changed their referral patterns. Moreover, their power to change hospital practices is de facto limited in many cases, because consolidation of services in many

OS52

HARRISON




parts of the country has left them a limited choice of hospitals.

Proponents of the 1990 act have pointed to the results of two major Department of Health initiatives as evidence of the act's success: (1) the waiting times initiative, and (2) the purchaser efficiency index. As part of the 1990 reforms, the government identified

long waiting times for elective procedures as reduction of one goal in its Patient's Char- ter.* Initially funds were targeted to reduce those lists on which waits were particularly long. Subsequently, a requirement was im-

posed on hospitals by the DHAs to continue to reduce or eliminate long waiting times. As shown in Table 1, the initiative appears to have been successful in eliminating very long waiting times. However, the total number of people waiting for elective treatment has remained at approximately 1 million, despite a higher level of hospital activity. Furthermore, these figures do not include the length of time people wait to see a hos-

pital consultant to be put on the waiting list.14 Indeed, it may be that GP referral patterns have changed, responding to the perceived speed at which a patient can be ex-

pected to receive elective care. The purchaser efficiency index initiative

focused on improvements in hospital output, as measured by the finished consultant episode or FCE. This measure differs from one used previously, the hospital stay or admission, which may comprise more than one FCE if the clinical responsibility for one patient is passed from one hospital consultant to another during a single stay. The total number of episodes or FCEs is the unit of measurement now being used to describe

*The Patient's Charter is the health services version of the Citizen's Charter, which seeks to implement standards of services for most public services. Specifically, the Patient Charter is a set of rights and standards for patient care delivery. It is expected that providers will be 100% compliant with the rights specified in the Charter, and in the course of time will be 100% compliant with the standards set therein.

TABLE 1. Hospital Waiting Times

1992 1995 Time Waiting (months) (% total) (% total)

0-5 69.5 76.9

6-11 21.9 20.0

12-23 8.5 3.1

24 0.1 0.0

Total waiting (in thousands) 939.7 1,044.1

Note: From Department of Health.

hospital output. Each year, a national target has been set for an increase in the number of

episodes provided. This target, currently 3%, is translated by DHA purchasers into targets for particular hospitals.

Strictly speaking, this initiative has also been successful. The number of FCEs have risen sharply in recent years. However, crit- ics of this measure are legion. The unit of measurement, the episode, is open to ma-

nipulation. For example, changes in admission procedures may increase the number of episodes, even though the treatment offered and the number of patients remains the same. Not surprisingly, the ra- tio of FCEs to admissions has risen stead- ily and varies from trust to trust. This rise

may reflect planned readmissions or unplanned ones resulting from patients be-

ing discharged too early. Or, as indicated, it may reflect changes in hospital organization, which may or may not improve efficiency.

A third policy initiative should also be mentioned. In general, English hospitals have been slow to introduce day surgery, but spurred on by an Audit Commission report,15 the government urged hospitals to increase the number of procedures per- formed in this manner. Although no national targets were set, many purchasers set targets of their own, leading to a sharp rise in the proportion of total surgical procedures carried out in outpatient settings in recent years.

OS53




MEDICAL CARE

These initiatives have combined to create a turbulent financial environment for hospitals, for although hospitals have continued to enjoy increasing financial resources, re-

flecting continuing growth in the NHS

budget as a whole, they have been required to produce with those monies continuously higher levels of activity, especially the reduction of waiting times. Efforts to meet activity targets have been derailed, in part, by growth in the number of patients admitted

emergently to hospitals-currently, roughly half the total admissions-numbers over which hospitals have virtually no control. This increase cannot, directly at least, be linked to any policy initiative, and indeed has been largely unanticipated. Further, it does not appear related to trends in demog- raphy or in morbidity, and despite a number of studies at the national or hospital level, the underlying causes and their relative im-

portance have yet to be established.16

Trends in Hospital Utilization

Changes in hospital utilization evident before the reforms are continuing in the

postreform period. Hospital admissions have increased by almost one third between 1984 and 1994, from 1,336 to 1,767 per 10,000 population. Demographic changes have played a minor role in the growth of admissions, with the bulk of the increase caused by rising intervention rates, particularly in the very young and the elderly. Lengths of stay have concomitantly fallen across all age and diagnostic groups (Table 2), and the overall decline is not caused sim-

ply by the elimination of very long stays. The net effect of the growth in admissions and reductions in the length of stay has been a decline in the total number of inpatient days of care. Indeed, although the average age of

hospital users has risen (Table 3), the share of inpatient days devoted to the elderly (ie, older than 65 years of age) has changed very little, in part as a result of a notable decline in lengths of stay for the elderly. Day case

TABLE 2. Length of Stay: Acute Admissionsa

Age (years) 1988-1989 (days) 1993-1994 (days)

All 6.6 5.4 0-4 3.7 3.1

5-14 3.2 2.5

15-44 4.0 3.4

45-64 7.5 5.7

65-74 9.9 7.5 75+ 13.3 9.7

aThese values reflect lengths of stay for finished consultant episodes (FCEs), rather than for patient admissions.


(ie, ambulatory) rates have also risen sharply for the period-from 176 to 499 cases per 10,000 population-with the majority of the increase occurring since 1991, likely engen- dered by the Audit Commission report en-

couraging the use of day surgery. The impact of these utilization trends are also seen in measures of hospital productivity, such as the

steady rise in the hospital sector's cost-weighted productivity index shown in Table 4.

Since the 1990 reforms, hospitals have seen a significant shift in the balance of their work from planned or elective to unplanned or emergent admissions. In the past, English hospitals have used surgical and "long stay" beds as a reserve to accommodate sudden inflows of patients, as occurs in periods of severe weather or during flu epidemics. The

rapid reduction in surgical inpatient work

TABLE 3. Percent Distribution of Admissions by Age

Age (yr) 1988-1989 1993-1994

0-4 16.2 14.1

5-14 6.7 6.0

15-44 30.1 28.3

45-64 21.4 22.8

65-74 13.2 15.1

75+ 12.4 13.7


OS54

HARRISON




TABLE 4. HCHS Cost Weighted Activity Index

Index 1983-1984 % Increase Over Year (100) PreviousYear

1983-1984 100.0

1984-1985 103.0 3.0

1985-1986 105.7 2.7

1986-1987 107.3 1.5

1987-1988 109.1 1.6

1988-1989 110.0 0.9

1989-1990 112.4 2.2

1990-1991 113.9 1.3

1991-1992 119.8 5.2

1992-1993 123.6 3.1

1993-1994 128.5 4.0


and in lengths of stay both for surgery and medical care has reduced the available bed reserves and the number of patients within the hospital who may be safely discharged at short notice to release a bed. As a result, English hospitals are working on very small reserve margins with occupancy rates around 90%, leading to a sustained, high- intensity work pace. Thus, when sudden

surges in admissions take place, significant pressure is imposed on clinical staff and on

patients who may have to wait before a bed can be found.

The hospital is becoming increasingly focused on diagnostic and treatment phases in which medical and technical contribution is

greatest, and less on recuperation and reha- bilitation phases in which the contribution

of nurses and professionals allied to medicine (eg, physiotherapy) are greatest. Conse-

quently, the number of medical staff and scientific and technical staff rose 26% and 51%, respectively, between 1985 and 1994 (Table 5), whereas nursing declined 14% almost

entirely as a result of a reduction in the number of students.17 Ancillary and other

support staff in hospitals have declined by more than half, largely because of the con-

tracting policy introduced during the early 1980s.

The increasing use of doctors in hospitals has required an increase in their overall supply that the government, which ef-

fectively controls entry into the profession, has been prepared to finance. How- ever, national policies reducing junior doctors' hours and restructuring post- graduate medical training in compliance with European Union rules have dimin- ished the existing labor force and made it hard for many hospitals to provide 24- hour medical coverage. As a result, many small general hospitals are finding it hard to maintain a full range of clinical services and are threatened with closure or with the loss of facilities such as the Accident & Emergency (A&E) departments (emergency rooms) or pediatrics. These trends have led to experimentation with professional roles and the transfer of work done by doctors to other professions. The Doctors' Tale,5 the Audit Commission's study of the use of hospital medical staff, notes several examples of the new roles emerging (Table 6).1819

TABLE 5. National Health Service Hospital Staff

1985a 1994a % Change

Medical 35,369 44,657 26

Scientific and professional 9,518 14,393 51

Nursing/midwifery 352,273 306,992 -14

Ancillary 154,159 72,815 -53

aWhole-time equivalents. Note: From Department of Health.

OS55




MEDICAL CARE

TABLE 6. Extract from The Doctors'Tale

Hospitals differ in how tasks are divided between junior doctors and nurses or other professional groups. In many hospitals, nurses and other professionals are now working in areas that were regarded traditionally as the province of doctors. These changes are the result mainly of attempting to reduce junior doctors' hours of work, or of responses to difficulties encountered in recruiting doctors.

They address only part of the skill question; the interface between junior doctors and other professions ...

* nurse practitioners in Accident and Emergency departments, and sometimes in wards which carry out basic duties like clerking patients (taking a patient's personal details and medical history) and insertion of intravenous cannulae;

* clinical nurse specialists, who work independently but according to guidelines agreed with doctors, have taken on some of the work previously done by doctors, principally in areas like intensive care, diabetes and care for the

terminally ill;

* midwives who are carrying out the tasks of some junior doctors in obstetrics; * new categories of support workers like phlebotomists and electrocardiogram

technicians; and

* non-medically trained surgeons'assistants who have been trained to do simple operations and procedures, notably in cardiac surgery. They work under direct

supervision of a consultant who is responsible for their work. Their tasks may also include assisting the surgeon at operations and clerking patients.

Source: Audit Commission, The Doctors'Tale, p. 18.

Quality of Care and Patient Outcomes

Assessing the full impact of hospital reforms requires information beyond the re-

ports on waiting times and other standards included in the Patient's Charter. Toward that end, there are three main sources of information on the quality of the care proc- esses in hospitals, which provide anony- mous data on a regular basis: (1) The National Confidential Enquiry into Peri-Op- erative Deaths, (2) The Audit Commission, and (3) The Clinical Standards Advisory Group.

The National Confidential Enquiry into

Peri-Operative Deaths (CEPOD), which is run

by the Royal College of Surgeons, has dur-

ing the years identified instances of poor performance in surgical procedures and the factors associated with it. Although the top- ics covered in the reports vary from year to

year, some themes such as the importance of

experienced senior staff to the provision of

high quality care are perennial. As shown in

an extract from a recent report, the enquiry, although based on specific incidents, aims to derive general lessons for application in acute hospitals (Table 7).

The second source of information is the Audit Commission reports. The commission

began as a purely financial auditor and it still retains that role. Yet, its general charge to investigate the efficiency and effectiveness of services has been flexible enough to allow it to report on clinical issues as well, particularly those around the organization of care. These reports have typically found a

great deal of diversity in service delivery among hospitals, as well as weaknesses in internal organization and communications.

Finally, the Clinical Standards Advisory Group was established in response to fears

expressed by the medical profession that financial and competitive pressures that were

expected to result from the 1990 act would reduce the quality of care. The Advisory Group, like the Audit Commission, takes different areas of hospital work and, using

OS56

HARRISON




TABLE 7. General Recommendations 1992/93

The National Confidential Enquiry into Peri-operative Deaths has again identified the substantial shortfall in critical care services. Any hospital admitting emergency patients, and hospitals admitting complex elective patients, must have adequate facilities for intensive and/or high dependency care at all times.

* Trainees with less than 3 years'training in the specialty should not anesthetize or operate without appropriate supervision.

* Practitioners must recognize their own limitations and not hesitate to consult a more appropriate colleague when managing conditions outside their immediate expertise.

* The skills of the surgeon and anesthetist should be appropriate for the physiologic and pathologic status of the patient.

* Surgeons operating laparoscopically should not hesitate to convert to an open approach when necessary.

* Appropriately trained staff must accompany all patients with life-threatening conditions during transfer between and within hospitals.

* The medical profession needs to develop and enforce standards of practice for the management of many... acute conditions (eg, head injuries, aortic aneurysm, colorectal cancer, gastrointestinal bleeding).

* There is an urgent need to improve the quality of medical notes. * Managers need to improve the services provided by medical records departments

so that notes are available when required.

Source: Report of the National Confidential Enquiry into Peri-operative Deaths 1992/93. Campling EA, et al. Confidential enquiry into peri-operative deaths 1992/93. London, 1995.

the results of research conducted in a number of hospitals, draws conclusions about the

quality of care being delivered. A recent report on hospital management of emergent and ur-

gent admissions identified a number of ac- tions that, it might be thought, any moderately well-run hospital would already have taken (Table 8).

Although these regular reports on quality process measures are available, there is no rou- tinely published data on patient outcomes in

English hospitals. There have been efforts to publish some statistical data on hospital care in the NHS through league tables.20 Yet none of the indicators in these tables relate to the outcome, effectiveness, or appropriateness of care, and instead focus primarily on waiting times for elective procedures.14'20 A number of clinical outcome indicators, including hospital death rates, are now regularly published in Scotland. These reports are new initiatives and, as such, have been issued cautiously, and their data

should be interpreted with care. The NHS is

intending to publish a limited set of indicators on hospital care in England for 1997.

It is worth noting that the current set of incentives for hospitals embedded in the 1990 act

promote improvements in throughput and volume rather than in quality or outcomes. It has been argued by Bums21 that:

...trusts should be paid by clinical results, as well as episodes. If, on case mix analysis, it seems reasonable to expect a certain defined standard of clinical care and a trust falls short of that standard, the trust should be financially penalised. Poor outcomes should lead to a poor income for a trust. Clinical performance would then become at least as important as financial performance to the trust and its chief executive.

At the time of writing, no moves in this direction are apparent. However, a number of initiatives have been undertaken that bear

OS57




MEDICAL CARE

TABLE 8. Summary of Selected Recommendations of the Clinical Standards Advisory Group on

Audit of Urgent and Emergency Admissions Management * Bed ownership and distribution

The move away from traditional "consultant ownership"of beds toward the development of more efficient schemes of bed pooling for urgent and emergency admissions, including reconsideration of bed closure strategies and the function of "hostel"or "hotel"beds.

* Urgent/emergency services organization Operational research on the optimal organization of admission and/or observation wards. Urgent move to provide 24-hour availability of emergency theaters.

* Clinical directorates-communication and management The further development of clinical directorates to ensure the full and continuing collaboration of managers and clinicians in use of resources for emergency services.

* Staffing Review of nursing and other professional staffing and distribution to meet needs.

* Availability of support services Audit of diagnostic and other supporting services to identify shortfalls and delays.

* Discharge planning The appointment of discharge coordinators.

* Information technology-intrahospital communications Exploration of potential uses of information technology to facilitate the rapid transfer of relevant information (ie, results of diagnostic tests) and improve communication with consultants on call.

Source: Clinical Standards Advisory Group, "Urgent and emergency admissions to hospital." Clinical Standards Advisory Committee. Urgent and emergency admissions to hospital. London: Her Majesty's Stationery Office, 1995.

directly on the quality of care hospitals offer. The 1990 act mandated clinical audits covering the work of doctors, nurses, and other professionals, though the results of these reviews are not published. A broader initiative in the area of outcomes has been the promotion of "evidence- based practice."The Department of Health has

supported a range of activities, including struc- tured research and development programs, information bulletins, and university-based centers specifically devoted to the assessment of evidence related to the effectiveness of inter- ventions. The information produced through such endeavors, it is hoped, will facilitate better

purchasing decisions by DHAs and GP fundholders for their patient populations.

In addition to these patient-level care effectiveness studies, a number of recent reports have begun to look at the organization of care and the merits of different forms of organizing

hospitals and associated services. For exam-

ple, the Department of Health recently ap- pointed an expert committee to review cancer services, which recommended establishing a network of hospital-based cancer centers with appropriate support services in other

hospitals and in the community. Similar reviews have been carried out in London, questioning the proliferation of small specialist units across all teaching hospitals, rather than concentrating these services more selectively. Such studies can be useful in effecting the organization of care at the level of the individual hospital, as well as for the population as a whole.

Future Developments

There are no official, or even generally ac-

cepted, forecasts of the future activity level

OS58

HARRISON




in hospitals, and the net effect of current trends is less than clear. Indeed, there is little doubt that some existing hospital services could take place in smaller institutions, such as community hospitals, general practitioners' premises, or patients' own homes. A number of initiatives, taken by general practitioners and those trusts providing commu-

nity health services, have resulted in the transfer of simpler medical procedures and

nursing and allied professional services for

postacute care to noninpatient settings. Yet, although there has been a great deal

of small-scale experimentation in shifting hospital services, larger-scale change has been hard to achieve. In principle, it was

thought that district health purchasers would be in a position to effect such shifts, but in practice they have failed to do so. The task of keeping hospitals in line with national performance targets has absorbed all their managerial capacity. If budgetary control continues to be shifted to GP fundholders, and if budgets for primary and secon- dary care are merged (they now form two distinct cash streams), then the incentives for shifting care away from hospitals will be increased.

Other budgetary changes could also affect hospital activity in the future. For example, increased funding for geriatric community services could reduce emergency admissions for the elderly who wind up in hospitals because of lack of alternatives. Another potential strategy is the development of patient management regimes in which the hospital's role would comprise diagnosis and decision making, with the treatment provided in a separate location. This may mean, for example, that instead of treatment in the hospital, the patient is referred back to a community-based professional. Develop- ments like these will be aided by information technology, which allows real-time access to hospital-based expertise. There are several small-scale examples of this in Eng- land, eg, minor injuries clinics linked to larger emergency departments.

One trend that can be expected to continue is the increasing specialization in medicine and nursing. The main factor lying behind specialization in the past has been the rapid growth in clinical knowledge, leading to the subdivision of general medicine and general surgery into a series of

separate specialties. However, further specialization unaccompanied by innovation in

working practices will have serious implications for the structure of the English hospital system, for if the basic concept of the district

general hospital is maintained, then the size of the hospital will have to grow. The notion of a general hospital serving its local population for nearly all their needs may be

gradually abandoned in areas that cannot

support the full range of medical or surgical specialties. A district general hospital in a sizable free-standing town might now meet 95% or even more of its population's need for hospital care. But if specialization continues further, then such hospitals will have to

begin "trading" with one taking over all pediatric care, for example, while another takes over all specialist cancer care (or within cancer itself, different hospitals might specialize in different sites). This form of trading is al-

ready common between smaller hospitals in

adjacent towns or within metropolitan areas. Further specialization would imply that most hospitals would have to work on this basis.

Conclusion

The English hospital system continues to be perceived by those working in it as being under continuous pressure. Waiting lists persist, and despite the extra activity in the past few years the numbers waiting have not declined. High occupancy levels have resulted in widely reported queues for beds, and in some cases hospitals have refused to admit local patients who have had to be transferred to other more distant hospitals. Many medical specialties are in short supply, leading some hospitals to import experi-

OS59




MEDICAL CARE

enced staff from other countries, including Western Europe, North America, and South Africa. There is a suspicion that lengths of

stay have been cut in an unplanned way to save hospital costs, even where the commu-

nity costs, eg, of home-based care, may be

higher. The pressures described here have stimu-

lated a number of changes. They have, for instance, created incentives to reorganize the flow of hospital work particularly in re-

spect to the treatment of emergency patients, eg, the introduction of admission or observation wards. They have also stimu- lated experiments in skill mix, including the substitution of nursing for medical staff, particularly in some of the shortage areas, as well as the development of specialist nurses to complement specialist physicians.

Currently, there is no consensus view of where these pressures will lead,22 and con-

flicting views on what the role and structure of acute-care hospitals should be. For exam-

ple, although some urge further hospital closures and the creation of regional super- hospitals serving perhaps 2 million people,23 others24 argue that most of what is currently done in acute-care hospitals can be dis-

persed to community settings, and still others argue for preservation of the status quo.25 Further concentration of services in

large hospitals would create incentives to shift additional care to other settings by ex-

tending the role of smaller subacute com-

munity hospitals or home-based services, thereby assuring adequate access to hospital services for the catchment population. This

approach is used, for example, in Oxford- shire, with the acute-care hospitals in Ox- ford itself discharging patients to smaller

hospitals in the towns in the surrounding county. This pattern has yet to be found in London, where there is no parallel system of small hospitals, or in many other parts of the

country where such hospitals have been closed.

There are signs26 that hospitals are re- thinking the organization of clinical work

both in respect to planned and emergency activity. But it is arguable that the main issues to be tackled lie in the financial and organizational framework within which Eng- lish hospitals work. As it stands, the current framework provides clear incentives to increase activity, but no clear evidence of the benefits of doing so. Indeed, many of the

failings identified by CEPOD and by the Audit Commission appear to stem from the way resources are deployed within hospitals, rather than from their low absolute level.

Improvement in the process and outcomes of care should become a priority for purchasers and providers of hospital services, and ought to be attainable even in a health- care system that makes, relative to those in other advanced countries, modest calls on the nation's resources.

References

1. Abel-Smith A. The hospitals 1800-1948. London: Heinemann, 1989.

2. Granshaw L, Porter R, eds. The hospital in history. London: Routledge, 1989.

3. Key T. Contracting out ancillary services. In: Max- well R, ed. Reshaping the National Health Service. New Brunswick, NJ: Transaction, 1988.

4. Dowie R. Patterns of medical staffing. London:

King's Fund, 1989-1991.

5. Audit Commission. The doctor's tale. London: Her Majesty's Stationery Office, 1995.

6. Audit Commission. Lying in wait. London: Her

Majesty's Stationery Office, 1993.

7. Maynard A, Bloor K. Introducing a market to the United Kingdom's National Health Service. N Engl J Med 1996;334:604.

8. Robinson R, LeGrand J. Evaluating the NHS reforms. London: King's Fund, 1995.

9. US Congress, Office of Technology Assessment.

Hospital financing in seven coutries. Washington, DC: US Government Printing Office, 1995. OTA-BP-H-148.

10. Jost TS, Hughes D, McHale J, et al. The British health care reforms, the American health care revolution, and purchaser/provider contracts. J Health Policy Law 1995;20:885.

11. Goodwin N. GP fundholding: A review of the evidence. In: Harrison A, ed. Health care UK 1995/96. Lon- don: King's Fund, 1996.

OS60

HARRISON




12. Audit Commission. What the doctor ordered: A

survey of GP fundholders in England and Wales. Lon- don: Her Majesty's Stationery Office, 1996.

13. Ham C. Population-centered and patient focused

purchasing: The UK experience. Milbank Q 1996; 74:191.

14. Radical Statistics Health Group. NHS "indicators of success": What do they tell us? BMJ 1995;310:1045.

15. Audit Commission. A short cut to better services: Day surgery in England and Wales. London: Her

Majesty's Stationery Office, 1990.

16. Edwards N, Warneke V. In the fast lane. Health Serv J 1994;104:30.

17. Buchan J, Hancock C, Rafferty AM. Health sector reform and trends in the United Kingdom hospital workforce. Med Care 1997;35:OS143.

18. British Medical Association. Towards tomorrow. London: British Medical Association, 1995.

19. Royal College of Physicians and Royal College of

Nursing. Joint statement on skill-sharing. J R Coll Phys 1996;30:57.

20. McKee M. Mortality league tables: Do they inform or mislead? Qual Health Care 1995;4:5.

21. Bums H. Making outcomes matter. Birmingham: NAHAT, 1996.

22. Harrison AJ. Acute futures. London: King's Fund, 1996.

23. National Association of Health Authorities and Trusts.

Reinventing health care. Birmingham: NAHAT, 1995.

24. Vetter N. The hospitals. London: Chapman and Hall, 1995.

25. Royal College of Physicians. Future patterns of care by general and specialist physicians. London: Royal College of

Physicians, 1996.

26. Merry P Back to the drawing board. Med Interface 1996;9:15.

OS61




3767247

Documents