Hospital closures: the taboo has been broken

The taboo has been broken. There is now debate about closing hospitals as an essential step towards improving UK healthcare.

“Save our local hospital” is the line of least resistance and not always the right one

Last month the free market think tank Reform called for some regions to shut more than a quarter of their acute beds. The study, Fewer Hospitals, More Competition, says the NHS has been right to reduce hospital beds by nearly half since 1987 - from 270,000 to 160,000 in England - but argues another 30,000 should go.

Doctors’ union the British Medical Association predictably condemned the report. It thundered that “cutting beds for purely financial reasons would be immoral and catastrophic for patient care”.

You might expect patient groups to be lining up to echo these sentiments. Some did - but by no means all. A letter in The Times with 46 signatories representing organisations as diverse as the British Heart Foundation, Asthma UK, Breakthrough Breast Cancer, the Sickle Cell Society, the Parkinson’s Disease Society and the British Association of Dermatologists disagreed.

Led by patient and carers’ coalition National Voices, they said: “Our members expect a wave of service changes including hospital closures as the NHS scrabbles to find some £20bn of savings. This need not be a bad thing. Too many people are admitted to hospital unnecessarily, stay too long and have a poor experience. Better care planning for the 17 million people with long term conditions would keep more people out of hospital, in better health and at less cost to the taxpayer. Not all hospital care is good enough, safe enough, or in the right place.”

Ramming the point home they concluded: “‘Save our local hospital’ is the line of least resistance and not always the right one.”

Three weeks later former health minister Norman Warner, writing in HSJ, attacked the platitudes from the politicians about protecting frontline services. Lord Warner highlighted the harm to the rest of the NHS caused by propping up uneconomic hospitals, and claimed many of the worst financial performers also had poor care standards.

Asthma is a compelling example of how better community services would slash hospital admissions. Each year around 80,000 asthma cases arrive at accident and emergency departments. Asthma UK believes a very high proportion of these could be avoided if all asthma sufferers had the appropriate support in the community. Similar arguments apply for a wide range of long term conditions.

The report for the Department of Health by consultants McKinsey into the likely impact of saving £20bn - leaked by HSJ last year - is stark in its analysis of bed occupancy. It compares UK spending on hospital care with other Organisation for Economic Co-operation and Development countries and shows that, at £1,009 a head, the NHS spends almost twice as much as Spain on hospital treatment and is second only to the £1,350 per head of population spent in the US.

McKinsey claims up to £700m is spent on hospital procedures having limited clinical benefit, and suggests some could be cut by as much as 90 per cent. Give patients better information about their options, likely outcomes and the risks, and many fewer opt for surgery, they argued. Examples cited included mastectomies, where the number of patients opting to have them almost halves. For prostatectomies a quarter dropped out.

Similarly, they claimed that up to £400m could be saved if the most prolific GP referrers brought their referrals more closely in line with the top 25 per cent.

McKinsey claimed around 40 per cent of patients in a typical hospital at any one time simply do not need to be there. The biggest causes were delays in the patient receiving hospital tests or therapies, and a lack of more suitable care facilities in the patient’s home or community.

Lines of resistance

A characteristic response to the McKinsey report came from BMA council member and consultant surgeon Anna Athow, who wrote: “The McKinsey message is that much NHS hospital care is not needed and, even if it were, must not be performed in hospital. Staff must be made redundant, wards closed, and hospitals allowed to ‘fail’… The work would be shifted into the community, meaning polyclinics, elective centres and walk-in centres, all in line with Lord Darzi’s reforms. Currently many of these are run by commercial companies.

“The McKinsey report seems to endorse a massive acceleration of the government’s reconfiguration and privatisation plans, using the funding cuts as the driver. What is actually being proposed is the denial of hospital care to millions of patients.”

Ms Athow’s article represents many of the lines of attack used against the McKinsey report: rubbish the private sector in general and management consultants in particular.

But there has not been a coherent rebuttal of the basic argument - that many hospital procedures should either not be happening there or not happening at all, while many patients want less treatment if given better information. Compare that BMA response with evidence from patient organisation the Picker Institute that a trial of shared decision making with patients in gynaecology led to a 40 per cent reduction in treatment costs.

“This evidence continues to be ignored by the NHS,” the institute said.

That is a serious allegation. Taken with the McKinsey evidence it implies the NHS, despite all the rhetoric about patient centred care, is institutionally failing to listen to patients or empower them to make informed decisions. This is not just poor care. Embarking on invasive surgery without giving patients the information to decide if that is what they really want is surely a breach of their human rights.

One foundation trust chief executive, asked what he planned to do to reduce unnecessary operations, replied: “I am not going to do anything. I am employed by my board to get as many patients in as possible, because every time they come through the door the cash register rings.”

The cap on patient numbers for the coming financial year goes some way to suppressing the ability of trusts to soak up cash by growing the volume of procedures. But there are strong reasons for suspecting many of the caps themselves include unnecessary procedures.

National Voices was right to highlight the keenness of hospitals to admit patients and their reluctance to discharge them. This particularly applies to older patients. Derek Wanless’s 2006 King’s Fund report Securing Good Care for Older People highlighted the continuing problem of delayed discharges and the poor progress in cutting avoidable admissions. According to DH statistics, people aged 65 or over in England account for well over one third of admissions to hospital and nearly two thirds of bed days.

The BMA is wrong to claim cutting beds would be “catastrophic for patient care”. There is compelling evidence, particularly from patient groups, that drastic cuts in admissions can be secured which would improve many people’s quality of life while bringing savings.

The new government needs to have the courage to engage in this debate. This is not just about spending cuts. The public must be weaned off the mistaken belief that the quality of healthcare depends on the number of beds. The reality of moving substantially more care into the community, empowering patients and cutting waste is that wards and hospitals need to close.