Centralisation is crucial to achieve better care locally

Last week Simon Stevens, the new chief executive of NHS England, gave his public support to community or “cottage” hospitals, which he said would restore “dignity and compassion” to elderly patients.

While he is right to champion the high quality care that “cottage” hospitals can provide, the NHS must not lose sight of the need to consolidate acute services into fewer specialist centres, allowing them to facilitate local services for the elderly and those with long term conditions.

• First interview with Simon Stevens: transcript, reaction and analysis
• More analysis and debate in HSJ’s Comment section

Keeping care out of hospital

There is an urgent need for investment in community based healthcare centres - including the more traditional “cottage hospitals” or “hubs” - that integrate a range of local healthcare facilities.

We have seen that commissioners, clinicians, social services and patients are in agreement that if done well these can improve patient outcomes and reduce the demand on our acute hospitals.

Such services are particularly important for the elderly and those with chronic conditions, helping them and their carers to better manage their condition, and therefore stay out of hospital.

In areas with a high prevalence of diabetes, for example, local services can be primed to provide specialist care to meet patient needs.

‘Rebalancing the way the national budget is spent must be done by reducing the spend consumed by the acute hospital sector’

This type of long term therapy management can take the form of multidisciplinary care planning, patient education, physiotherapy or clinic appointments - none of which needs to take place in an acute hospital setting.

The problem is that providing this type of care is expensive.

It is affordable only on the premise that it reduces the demand on acute services.

As HSJ revealed last September, the amount the NHS spends on acute hospital care continues to rise, currently consuming 51 per cent of the total budget.

To fund aspirations of locally led, community provided healthcare, the only available option is to rebalance the way the national budget is spent, through reducing the spend consumed by the acute hospital sector.

Strengthening local links

Mr Stevens has an unprecedented opportunity to transform the NHS and safeguard its future.

With clinical commissioning groups now firmly established, he has a mechanism through which real improvements in community based care can be effected.

‘We are beginning to see fresh ways of working and new investments that will secure better access to GPs and integration of care’

Local clinical commissioners now see the opportunity to transform the way care is delivered to their communities, and local partnership working has never been stronger.

Across the country we are beginning to see fresh ways of working and new investments that will secure better access to GPs and integration of care across different providers.

Programmes such as the recently announced prime minister’s £50m “challenge fund”, and local pioneers for the implementation of whole systems integrated care will enable much needed investment in community based care and improve outcomes for patients.

Centralisation is crucial

If more care is successfully delivered in the community, unnecessary attendances and admissions to acute hospitals will be prevented and the demand for acute services will reduce, but the demand that remains will be from patients with more acute or specialist clinical needs.

Add to this the financial challenge of the 24/7 senior doctor presence - which is increasingly accepted as a necessity - and centralisation of certain services becomes a must.

There is also increasing evidence that continued centralisation of services is necessary and can save lives.

‘If you designed the NHS from scratch today you would not create acute services in their current form’

A recent review of the decision to reconfigure stroke services in London in 2010 concluded that the centralisation of these services has saved 400 lives in just three years, with the survival rates 90 days after having a stroke rising from 82-89 per cent.

Not only did the reconfiguration save lives, it was able to save £811 per patient episode, while providing higher quality care.

We should not centralise services for the sake of it, but it is clear that if you designed the NHS from scratch today you would not create acute services in their current form.

The clinical and financial case for transformation is overwhelming.

An increasing body of evidence, including the ongoing Keogh review, provides a clear platform for change, and further consolidation of acute and specialist services would transform the clinical outcomes for thousands of patients in the NHS every year.

Be brave

We need bravery from both NHS leaders and politicians.

We must be honest about the need to do things fundamentally differently if the NHS is to survive.

Huge amounts of time and resources have been wasted on programmes to redesign and reconfigure services which have foundered on the rocks of opposition from the public - who see only cuts to local services - and politicians - who feel obliged to oppose change to appease this public opinion.

‘We need cross-party agreement to localise where possible and centralise where necessary’

The recently abandoned attempt to reconfigure paediatric cardiac services across the country is perhaps the highest profile example, but there are many others.

It is time to take politics out of the NHS: we need cross-party agreement to localise where possible and centralise where necessary.

These will not be easy goals to accomplish, but the first steps are already being taken.

Paradoxically, it is only through greater centralisation that higher quality, community led services will be achieved.

Sam Burrows and Kate Woolland are health experts at the PA Consulting Group