Near or far: the cyclical debate about what hospitals are actually for

Near or far: the cyclical debate about what hospitals are actually for

In an interview for the Telegraph last week, NHS England CEO Simon Stevens set out the unfashionable case for smaller hospitals – citing they would do a better job for elderly people at the end of their lives. In doing so he was making another contribution to a debate that has constantly swung back and forth in recent decades.

Recent years have seen big, and long overdue, centralisations for trauma care and stroke services. But it is less than a decade since publication of Lord Darzi’s controversial plan for beefed-up GP ‘polyclinics’ that would be able to provide services normally associated with hospitals in communities.

This continued back-and-forth reflects an ongoing anxiety about what hospitals are for – and whether they are still appropriate for the healthcare needs of the 21st Century.

There is no question that if you are relatively young and experience a catastrophic episode of ill health, then a specialist full-service teaching hospital is exactly where you need to be.  This conception of a hospital as a place in which people are ‘saved’ dominates much of the media and political discussion about how healthcare is provided.

But as Mr Stevens points out, the majority of modern hospital activity is in fact focussed on slowing the decline for the very elderly. A ‘typical’ patient in need of NHS care might be better thought of as someone undergoing the late stages of undefined organ failure and cancer. And although the well find big hospitals reassuring, organisations such as Macmillan Cancer Support find those with terminal illness would chose to end their lives anywhere but hospital.

A cynic might put Mr Steven’s defence of small local hospitals down to an unwillingness to grasp the nettle of hospital reorganisation – the recent bruising failure to change paediatric cardiac surgery looms heavy in the minds of health policy makers.

However, a parallel debate around integration of health and care has to date centred on coordinating the efforts of GPs and domiciliary care with the aim of keeping old people out of hospital for as long as possible. Stevens’ intervention reflects a need for this integration debate to switch more specifically to the secondary care arena as well.

Care home providers are now looking at providing a greater range of formal healthcare services in their facilities and hospice places have always been vastly oversubscribed. There is a future for both local and specialist hospitals, but they might need first to define themselves better in the public mind. Getting closer to meeting the real needs of their patients is definitely the right way to start.

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