It is five years since I raised the
topic of a 24 hours a day/7 days a week hospital service with Mr. Lansley. (see previous blog) It is good to see that the present government
is showing an interest in the idea and some determination to bring it
about. It is less encouraging that the
response from our medical colleagues has on the whole been negative.
At the base of the opposition, I
think, is a misunderstanding. If the
whole hospital service were to go from working on average, say, in the region
of 10 hours a day and five and a half days a week (which is a guess, not an
accurate estimate) this would amount to 55 hours a week. To make all the hospital facilities work 24
hours a day and seven days a week would raise this to 168 hours, i.e. it would
expand the hospital service threefold!
Whereas this might be thought desirable in theory, it is quite clearly
impossible in practice and the proposal to go to a “168 hour per week service”
is quite different.
If in a large medical centre a
number of services - the operating
theatres, the diagnostic departments and the acute medicine departments were to
go to 168 hours per week, then it would need to follow that a much of these
services currently provided on the 55 hour a week model in reasonably nearby
hospitals would have to be discontinued.
One can envisage that some hospitals might close altogether, thereby making
large savings on the maintenance of the estate and on the administration which
are both expensive. The relevant staff would be transferred to the 168 hour a week
hospital to enable it to function at that level.
However, there is also a real need
for “low intensity” hospital facilities which used to exist and have largely
disappeared. There has been much
discussion of bed-blocking by patients who have no need for intensive
facilities but for whom there are no facilities in the community, and there are
also other patients who still require some degree of medical care but who do
not require the expensive facilities of an acute hospital. For such patients, it would be desirable to
have low intensity hospitals which provide accommodation, nursing care and basic
medical care but without the expensive facilities to be found in the large
hospitals. Some years ago it was
estimated that a high intensity bed cost £500 a night and a low intensity one
£100 a night, so that there are also large savings to be made here.
Quite clearly, changes of this
description cannot be brought about nation-wide, or all at once. In urban areas, or in regions where there is
a large hospital within reach, such changes may be made without the need for
training new staff and the added expense of paying staff for unsocial hours
would be more than recompensed by the savings that can be made by reducing
activity in the surrounding hospitals. Where
this looks feasible, it could be initiated quite quickly. In other areas where the distance of travel
would make for serious problems, the arrangements may be more difficult to
bring about. In any case gradual introduction of change with the old and new
systems running side by side, will allow comparisons to be made - seeing where
the benefits and the difficulties lie and seeing which delivers more QUALYS per £. Sad
experience has shown clearly enough that this is always preferable to trying to
introduce nationwide, untested changes
tied to an electoral timetable!
The situation with regard to general
practice is quite different but here also one can envisage changes being
gradually brought in which would reduce the existing work-load while allow
seven day a week access.
A major change that has occurred in
general practice since the introduction of the NHS, has come with major
advances in medicine which have led not to the cure of chronic diseases but to their management. There are now large
numbers of patients, and not only the elderly, that suffer from chronic
conditions such as diabetes, hypertension, asthma and chronic lung disease, angina
and chronic heart disease, rheumatoid arthritis and related rheumatological
diseases among others, who require regular assessment and care over many years.
This care has increasingly been put onto general practitioners. This, however, is contrary to the clinical
evidence. There is good evidence most of
these diseases, that patients’ outcomes are significantly better when they are
cared for in specialised clinics set up for their particular disease. This is by no means surprising. Not only it is probably advantageous for doctors to see many instances of these
diseases rather than a few, but such clinics will also have access to
specialised ancillary services (for example dieticians and podiatrists for
diabetes, as well as the diagnostic services that are required. Furthermore clinical trials on newer treatments
are easier to carry out in this environment., There is therefore be a strong
case to be made for establishing diabetic clinics, hypertension clinics,
chronic respiratory disease clinics etc in large central hospitals where outpatient
care is provided for the management of
long-term conditions. It is almost
certain – and could be properly evaluated - that this would improve outcomes. It would also save a great deal of time in
general practice which would allow GPs to concentrate on their other functions
and to provide a seven day a week service.
Again, such changes cannot be brought in all at once and would have to
be allowed to develop slowly where the conditions are favourable. All these changes should be closely monitored
so that, again, their value in QUALYS per £ spent can be evaluated.
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