Third of acute care 'not needed'

24 October, 2012 | By The Press Association

A third of acute services in the NHS are not needed, the NHS Confederation has said.

Mike Farrar, chief executive of the body which represents all health service organisations, said that 30 per cent of patients treated in acute care could be treated elsewhere in the health service.

Mr Farrar told the health select committee that a “big chunk” of the government’s £20bn efficiency drive needs to be found in acute services.

“We would effectively be able to operate with a much smaller acute base,” Mr Farrar said.

“Not that we would be able to get rid of it entirely but we would need a smaller acute base for acutely ill patients.”

He said that assessments which test whether inpatients need hospital services have found that 30 per cent to 40 per cent could be treated elsewhere.

“I think we could be talking at least 30 per cent of our acute capacity which we do not need,” he said.

In order to reconfigure hospitals, it would be “absolutely critical” to strengthen GP services, community care and social care, he added.

Readers' comments (27)

Anonymous | 24-Oct-2012 12:59 pm
Bang on, Mike
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samantha grainger | 24-Oct-2012 1:07 pm
Where is the evidence that the care in the Community is cheaper. Granted bringing services closer to the patient may offer benefits but would it be affordable? I have yet to see any evidence that all the savings that are being bandied about can actually be achieved - where? As saving are made in the Acute sector there would need to be serious investment in the Community sector both to improve facilites and support the growth in activity.
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Anonymous | 24-Oct-2012 1:31 pm
And what do we do with all the bloody hospitals we've built/PFI'd??!
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Anonymous | 24-Oct-2012 1:32 pm
Let's give it a try - why don't we close a third of the acute beds in London (everybody knows London is grossly over-supplied with hospital beds) for a week and see how we get on.
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Ed Macalister-Smith | 24-Oct-2012 1:49 pm
I am entirely confident that the headline comment is right, and Confed should continue to challenge the system and politicians to move towards this vision, and to deal with the inevitable consequential downsizing impact on acute services.

But this should not be seen as some kind of negative attack on acute services or their staff, who work hard within the current environment to provide good care. Nor is it a let-off for community services, nor for primary care services. This should not just be about more-of-the-same from those two sectors.

The recent TCS process revealed fairly wide-spread inefficiency in community services, and there are opportunities for significant innovation and productivity improvement.

Similarly, general practice providers need to come to terms with the 24/7/365 implications that care outside of hospital implies, and while a few practices understand this, most don't yet. This is not about more-of-the-same, but about fundamental redesign.

Good luck CCGs in making this happen!
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Patrick Newman | 24-Oct-2012 1:49 pm
Wow Losing 30% of acute capacity but who is going to implement that. NHSCB, Monitor OFT DH or a plenary of all the CCG's!. Yes Samantha is right. Is the 'business case' to be published backed up by credible peer reviewed numerical analysis? Will the 'declining' FT's and trusts be voting for a Christmas roasting on the fire of re-configuration? The more privatisation the more complex this programme will become. Currently the NHS is only playing with this idea.
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Mike Coupe | 24-Oct-2012 2:14 pm
some refinement of the argument is needed: 30% of acute (specifically medical emergency) activity does NOT equate to 30% of capacity. Audits over the past few years have consistently pointed to unnecessary admissions equating to 20-40% of workload. But if those admissions are referred back to the community on the same day or within 1-2 days - set against an ALOS of say 5 days - then the capacity potentially saved is actually quite small. The second issue is the efficiency of alternative community based services. A ward is actually a relatively efficicient service delivery mechanism.
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Tom Dewar | 24-Oct-2012 3:22 pm
Lack of evidence aside, can someone tell me how this squares with Circle's plan to address the financial problems at Hitchinbrook, in part, through growing their Acute activity? As a specific example.
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Anonymous | 25-Oct-2012 8:13 am
Shambles
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FRANK FITZPATRICK | 25-Oct-2012 10:30 am
Advertisers often says they are sure half of their spend is wasted. The problem is that they don't know which half. Let's close a third of acute places then see what happens to politicians and NHS chiefs after the next terrorist attack! I'm not saying that's a reason for keeping places open but it shows there are a lot of factors to take into account before you get out the surgical saw rushing to £20 billion cuts is not one of them. Lemmings may not commit mass suicide but the NHS seems to want to throw itself off a cliff.
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Clive Peedell | 25-Oct-2012 11:03 am
Let's put this into some context:
The NHS Confed receives 50% of its funding from the DH, so is effectively a mouthpiece for the DH, which wants to make £20 billion QIPP savings (to begin with). The DH has already made it clear that it wants to achieve this in part by transferring as much work as possible into the community.

The 30% figure is wildy optimistic or pessimistic (whichever way you so it!). Firstly, many patients who present acutely still need to be come to hospital for investigation. They need a diagnosis and a treatment plan before being discharged. It is only after this assessment that decisions can be made. Some of this assessment sometimes needs to be done as an inpatient, but not all of it. If the patient is well enough to go home, then they should be sent home with an appropriate care plan.
Sometimes patients have social issues and need admission on that basis. This can only be addressed by adequately funding Social Care eg Dilnot etc

Finally, I think most acute physicians who are struggling to find beds in an almost constant battle with bed crises, would baulk at Mike Farrar's comments.

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Anonymous | 25-Oct-2012 1:20 pm
Its essential that we see the evidence and assumptions behind this kind of statement, both the acute saving part and the implied lower cost community alternatives (implied if this is to contribute to QIPP savings).
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Anonymous | 25-Oct-2012 1:23 pm
It is too easy for people like Mike Farrar to spout this kind of thing from his distant ivory tower. He's said it, so lets insist that he explains it in detail. I suggest HSJ devotes a whole issue (or a special issue) to Mike Farrar and his analysts appearing before a specially formed committee of informed, senior clinicians and managers, to work through the suggestion.
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Anonymous | 25-Oct-2012 1:47 pm
Let's assume that Mr Farrar is correct in his assertion that 30% of capacity could go.

Let's now look at a typical town/city where the residents use its one and only hospital.

The fixed costs associated with running a site at 70% capacity probably aren't much different to 100% (when "care and maintenance" is considered), and disposal is unlikely to be an option given the piecemeal nature of the unused capacity.

So will there really be much left over to plough back into other services? Rather sceptical.
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Anonymous | 25-Oct-2012 1:59 pm
I think people have missed the point...look at the Black Report from the late 70's for example, if we spent more time on prevention and making sure people didn't get ill in the first place then we wouldn't need so many hospitals! As I heard from someone once, we are a national sick service rather than a national health service. The problem is the politicians are more interested in being re-elected than they are in understanding what is good for the nation and the NHS, if this wasn't the case then we might actually get somewhere! Remember the saying prevention is better than cure...?
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Brian James | 25-Oct-2012 3:19 pm
There is plenty of evidence to support the claim that c.30% of admissions are for conditions wholly susceptible to care outside of hospital. The question is how much of that 30% is because of the absence of appropriate and suitable alternatives, the the speed (or rather lack of it) with which those alternatives can be brought to bear - if not in real time, then the default and safe option is admission. The problem is that significant investment is required in developing those alternatives BEFORE we start shutting wards and beds, and in the current financial climate there is insufficient money available to do this whilst having to prop up the existing system.
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George Webb | 25-Oct-2012 4:14 pm
Let acute trusts operate as GPs surgeries do and save even more. The private sector can plug the gap at a lower cost. Problem solved?
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KEVIN PRITCHARD | 25-Oct-2012 7:15 pm
Interesting, dare I say, slightly inflammatory article - great headline, almost Daily Mail...

Anons' suggestions at 1.20 and 1.23 would be great to see via webinar - you'd sell tickets to that!

Go on HSJ - do some journalism - stop just reporting quotes?

KP
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Anonymous | 25-Oct-2012 9:29 pm
I think Ed Macalister-Smith is close to the mark here. As Roy Lilley recently blogged patients head to the place 'where the lights are on'. Acute's then do what they're configured to do resulting in over-investigation, un-necessary admissions etc etc. I'll health (& the cost of I'll health) will not be managed unless we fundamentally reform both public health and primary care (predominantly GP) practice - the 'overuse' of the acute sector is essentially because that sector is plugging gaps & failures elsewhere.
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Maggie Harding | 25-Oct-2012 9:47 pm
I may be cynical but what I wanted in 2009/10 was a really severe flu pandemic which woud have forced us collectively to sort the essential from the desirable and discretionary. In terms of outpatient activity, acute admissions and ITU admissions this might have revealed how much of what, without an NHS crisis, we consider essential is in fact desirable or even discretionary: hospital admission for minor GI bleeding, chest pain without good evidence of MI, acute on chronic COPD, CHF, TIA, minor stroke beacuse the evidence of benefit in terms of oucome is questionable. The same rationale may well apply to much elective surgery and routine outpatient activity.

As we were not forced to triage use of an exceptionally constrained bed base we will never know, but there is a case for dismantling a proportion of the existing beds and evaluating whether this affects outcome.

Some of us remember the early days of junior doctor industrial ctivity which demonstrated that the rate of deliberate self harm (presenting to A&E) reduced significantly. Given we are now much better at enumerating both activity and outcome this could and probably should be subject to more rigorous evaluation.
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