OVER THE WALL

We don't hear much about the 'acute revolution' these days.

The focus on primary care groups and trusts, and partnership working in the primary care-led NHS may well be refreshing, but where does the acute sector fit in? It is five years since the then health secretary, Virginia Bottomley, predicted that early in the new millennium 80 per cent of surgery would be keyhole, 60 per cent of operations would be on a day basis, 40 per cent of specialist consultations would take place outside hospitals, and 40 per cent fewer acute beds would be needed.

Even if these predictions are not entirely accurate, they hold huge implications for the NHS. Any attempt to address the proper use of acute hospital services must include long stay hospital provision, primary healthcare, community health services, social care and the role of carers, examining their inter-dependent relationships. But while the intersections between primary and community care are scrutinised ever more closely, the position of acute care seems less clear.

Acute sector changes have cost implications for other agencies, but the difficulty of estimating these has led to a tendency to ignore them. The organisational fragmentation bedevilling our welfare system has exacerbated the problem - hospital doctors and GPs have tended to remain two distinct groups, while local government's health role has been systematically dismantled.

Perhaps the weakest and most neglected relationship has been between acute and social care, yet neither can ignore it. 'Quicker and sicker' discharge, referrals to social services from hospital staff, placements in residential and nursing homes, and the changing role of home care are examples of the two sectors' inter-connectedness. But evidence from a recent survey of joint investment plans identifies lack of engagement of the acute sector as a recurrent theme.

1 Even less attention has been paid to the acute revolution's impact on carers.

Changes in the location and pattern of acute healthcare rely heavily on the availability of carers to support friends and relatives at home, and local authorities now have a duty to assess carers' needs for services in their own right. The most heavily involved carers are the least likely to receive help from services, and any redress will be yet another cost-shunt from the NHS to local government and from free to means-tested support.

While we may now know more about 'bed-blocking' and unplanned re-admissions, we remain woefully ignorant about discharge outcomes, which stagger along on the back of carers' input.

There are two ways of dealing with this: collaboration or integration. The first step in a collaborative strategy is a clear understanding of interdependencies and of the ways in which a joint approach can benefit all parties - a very different proposition to cost-shunting. Examples of small projects like this are sprouting around the country, often on the back of ringfenced winter-pressures money.

The real challenge is to move from small, and sometimes ephemeral, projects towards mainstream integrated community-based care - indeed, acute trusts may see this as their salvation in the face of the anticipated reduction in hospital beds.

2. 'Shared care' schemes in which GPs, practice teams and community health staff take on some or all of the routine management and monitoring of patients traditionally undertaken by hospital doctors in outpatient departments are not new, but neither are they widespread.

Supporting older people will be the biggest challenge, and will need to encompass acute assessment and care, rehabilitation, respite and continuing care. Straddling so many traditionally disparate boundaries will not be easy - one study simply concludes it is 'probably unattainable'.

3 If collaboration is problematic, one alternative is waiting in the wings - organisational integration. It is fashionable to denounce further restructuring and to argue that it would simply create other boundaries, but seamless support is far more likely where the same factory does all the stitching.

While the internal market worked against a shared approach, the current NHS reforms offer an opportunity for integrated commissioning and provision of closely related activities to support people in the community.

The key to capitalising on this is the future shape and role of PCTs. We know they will act as integrated providers and commissioners of primary and community healthcare, but this leaves two crucial factors out of the equation: social care and acute care. PCTs will have no direct commissioning or providing remit for social care, but one effect of the partnership flexibilities in the new Health Act w ill be to create a spectrum of relationships between PCTs and social services, some of which will be effectively integrated organisations.

Where will this leave acute trusts? If the NHS's future is the management of chronic illness in the community, it makes little sense to have separate organisations for acute care. Patients' interests will be better served by integrated local health agencies . The more routine services required by most patients will be provided in local hospitals or in primary care settings, while LHAs will join together to organise high-technology healthcare in a small number of regional centres of excellence. Integration does not stop at the doors of current acute hospitals.

REFERENCE

1 Jones N, Lewis H. Joint investment plans for older people . Nuffield Institute for Health, University of Leeds,1999.

2 Henwood M. Tipping the Balance: the implications of changes in acute healthcare for patients and their families. NAHAT, 1995.

3 Pritchard P, Hughes J. Shared Care - the future imperative? Nuffield Provincial Hospitals Trust, 1995.

Bob Hudson is principal research fellow at Leeds University's Nuffield Institute for Health.