Stephen Eames on defending district general hospitals

How else can integrated models of care come anywhere near to fruition - or the scary amounts of savings found?

At the centre or the periphery of all of this - depending on your vantage point - is the district general hospital.

New community and primary care services must replace rather than add to those provided by acute hospitals and be cheaper to provide

If, like me, you have a nerdy interest in the history of this much loved institution, you will know that the underlying debate is not a new one.

There are roughly 160 DGHs in England offering at least core acute services. While their management, structures and systems have changed, their essential make-up hasn’t altered much since Enoch Powell’s 1962 hospital plan. Indeed, the NHS Plan of 2000 focused on increasing the number of new hospitals, further reinforcing the dominance of the DGH.

In the past decade, two major trends have challenged the continuance of the district general as we know it: moving less complex services out of hospital into the community; and the concentration of more complex specialist clinical services in bigger hospitals on the grounds of clinical safety and quality.

These have been undertaken in tandem with the modernisation of acute hospital services and a greater focus on the needs of individual patients. These themes are central to the implementation of High Quality Care for All and the programmes of transformation we are all pursuing.

The policy of providing care closer to home has a long and chequered history. In local large scale discussions with the public, there is always widespread support for clinical systems and processes that deliver care closer to home rather than in hospital.

However, evidence for the cost effectiveness of this is still inconclusive. The challenge will be to persuade the public that applying this policy will mean a concomitant reduction in hospital beds and services.

There is evidence that, for complex acute care - for example cancer, cardiac and major vascular surgery - services and hospitals that perform a high volume of procedures have better patient outcomes.

So the case for centralisation of services, often further away from home, is strong. There is probably less consensus about the mass centralisation of more common procedures, but the inexorable trend towards specialisation and sub-specialisation increasingly favours a health system comprising larger hospitals offering a wider range of specialist care.

The DGH is a resilient brand but numerous pressures in the environment abound. These include the potential for powerful commissioning strategies to drive horizontal and vertical integration and to continue to strengthen services outside hospital.

There is also increasing pressure from patients, the public and regulators for continuous improvement in health outcomes which will reinforce and inform the choices that people make about their healthcare needs.

Add to this pressures arising from changes in education and training, the working time directive and supply shortages in some professions. This is all capped with the funding and cost issues of the economic climate. So the challenge is on - transform or die.

As always, there are other wicked problems. First, there is still no well developed body of research that can effectively demonstrate how the quality of care provided in community or primary care settings compares with that in acute hospitals.

Also, for any reconfiguration to generate savings - an absolute prerequisite in the current climate - the delivery of services in the community will need to be more cost effective.

So, new community and primary care services must replace rather than add to those provided by acute hospitals and be cheaper to provide. This is a tricky area as the research has yielded mixed results.

For example, research by the King’s Fund identified one randomised controlled trial of patients requiring non-urgent treatments for skin problems that found “considerable additional cost” associated with treatment by a GP with special interests compared with traditional outpatient treatment.

In contrast, another study found that early discharge and home care was nearly 25 per cent cheaper than standard hospital care. In addition, several reviews of A&E services show that minor injury units, NHS walk-in centres and NHS Direct has not reduced A&E attendances - except possibly where services are on the same site.

So, how will the next stage in the history of the district general hospital develop? At a minimum, the future DGH will need to provide high quality, low cost performance, probably with other providers.

They will need to be flexible enough to compete aggressively for some services and collaborate on others. They will have to learn to develop services where they have competitive advantage and to divest themselves of those services where they don’t.

Most of all, they will need to be nimble and diversify wherever they can and play a strong local role in primary, community and social care, winning the hearts and minds of patients, staff and politicians along the way.