An NHS accountant who has worked in the NHS for the last 20 years raised an interesting point at a meeting this week.
He explained why GP commissioning consortia (GPCC) which are replacing Primary Care Trusts (PCTs) are supposed to provide care for 500,000 patients. I had been wondering what good it could possibly do to combine 3 local PCTs, City and Hackney (200,000 patients) with Newham and Tower Hamlets with such diverse and complex populations to make one huge GPCC. I’ve been complaining for a while that this will make it very hard for GPs to work together and there will be far less local accountability and responsiveness to patient needs.
But the accountant told me that for most of the 20 years he had been working in the NHS it was common knowledge (among NHS accountants) that the ideal hospital catchment area was approximately … 500,000 patients. With an estimated population of 8 million, that makes … 16 hospitals.
According to the Darzi plan for healthcare in London: (summarised by Anna Athow in 2009)
London’s 33 DGHs (District General Hospitals) would be reduced to 8 to 16 acute major hospitals. The plan says “ The days of the district general hospital seeking to provide all services to high standard are over”. Many London DGHs would lose maternity and paediatrics. There would be fewer A&E departments and more urgent care centres. ( Lord Darzi interview with Guardian 11.7.07)
“Local hospitals” could have an A&E unit admitting acute medical admissions but without emergency surgery, 24 hour diagnostics or intensive care on site. The plan proposes that emergency doctors could resuscitate, intubate and ventilate patients requiring emergency surgery and transport them to an acute major hospital for their operation. ( p 65 150 Acute Clinical Care From Cradle to Grave. P 13 Report of the acute clinical care working group)
The NHS changes, costing an estimated £3bn, are the biggest and the most expensive in the 60-year history of the NHS. At the same time the NHS has to save £5bn every year for the next 4 years, something no health service in any country, anywhere, ever has managed. See this excellent explanation by Richardblogger of why this will be impossible without closing hospitals (or changing their minds about the cuts). The Department of Health has estimated that GP surgeries will, on average, have to save £2500 a day. Despite the fact that we have spent less on healthcare than almost any European country for the last 30 years, the government thinks we spend too much. These savings will only be possible if hospitals close and thousands of NHS staff lose their jobs.
In order to avoid responsibility they are giving most of the NHS budget to GPs and are forcing them pay private companies to do the work the NHS has done for years, but at a bargain prices. The coalition has set up an enforcement agency called Monitor to make sure the GPs accept the cheapest bids. When services close, GPs will be blamed for mismanaging the budget, even though they were trained to look after patients.
I am prepared to stick my neck out and suggest that perhaps we do have too many hospitals. We might even have twice the number of hospitals we need. The accountants might be right and healthcare might be safer and more effectively delivered from fewer hospitals. But surely if you’re going to make changes of that magnitude, they have to be carefully planned. One senior policy adviser tweeted to me last week, ‘planning is a dirty word’. So instead of planned, coordinated closures we have a quasi-market in which hospitals will close because they’re insolvent due to poor financial management or because they cannot survive in a market where prices are undercut and services cherry-picked by private providers. Hospitals will have to follow the money instead of being planned according to clinical need.
If politicians think hospitals have to close, they should have the courage to say so, and take responsibility for it.
A government that delegates this responsibility to the market has no right to govern.
As the founder of the NHS, Aneurin Bevan said:
“The NHS will last as long as there are folk left with the faith to fight for it”
To preserve an NHS where patients, not profits come first:
- send your views to info.whitepaper@bma.org.uk
- join Keep Our NHS Public
- find out more from the NHS Support Federation
A Better NHS 
I feel the hand of David Kerr in this. David Kerr produced the ‘Kerr Report’ when he was up in Scotland and it was responsible for the ‘slash and burn’ approach to level 3 hospitals up here; ie they were going to shut half of them and replace them with community casualty units. It was a nonsense. The SNP did save Monklands (my local hospital) and Ayr Hospital, but the fallout from it is that Glasgow lost Stobhill, the Queen Mum maternity and Yorkhill hospital for Sick Children; these are now going on one campus in the south of Glasgow and we have the Royal in the north. Nobody’s asked themselves what happens if there’s an accident in the Clyde tunnel or on the Kingston bridge and these are not accessible. It’s nuts.
“I am prepared to stick my neck out and suggest that perhaps we do have too many hospitals. We might even have twice the number of hospitals we need. The accountants might be right and healthcare might be safer and more effectively delivered from fewer hospitals. ”
I too will stick my head with you on that. That’s why I U-turned on the Polyclinics, or mini hospital and was convinced they were a good idea after an initial rejection, because had they been fully implemented ‘properly’, they would have provided a comfortable and modern alternative to all the corridors and dilapidated sites of some current hospital sites. I never been a fan of that and never got attached to bricks and mortar either, but to the people within and the service they provide, and that, as you have implied, is the part that hurts most, those people losing their jobs and where are they all going to go now that the polyclinics have been halted too?!
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Hospital closures are highly political. Four years ago we had the Acute Services Review and there was a lot of protests about the prospects of one hospital or another losing its A&E. Noticing an opportunity to gain an advantage the politicians waded in. (Ah here we are “Cameron has promised a “bare knuckle fight” with Prime Minister Gordon Brown as he launched a campaign to safeguard district hospitals.”)
But when the boot is on the other foot, they change their mind. Cameron promised that maternity units would not close if local GPs were against it, yet Lansley approved the closure of consultant-led maternity unit at Maidstone at the end of last year even though the public and local GPs were against the closure.
This is where “liberation” comes in. Lansley’s plans are to liberate him from having to make this decision. The result is that the market decides.
Look at how the market has failed in our privatised energy supply. Without a strategic plan to build power stations it means the lights will go out in the next few years as ageing power stations fail (7 of the country’s 14 coal-fired power stations must close by 2015). The market failed to make sure that new power stations were built (OFGEN says we need £200bn of investment in the next decade, who will provide that?) and now we are getting close to a crisis point.
The same will happen in acute services. The market is a blunt tool. Local hospital bosses are not skilled in explaining why they have to re-configure services and the public will complain. Strategic decisions will not be made and the result is that we will get a poorer service over all. The people who could have taken leadership over such matters will be washing their hands, telling us that it is not their responsibility.
Well, we have to make it their responsibility. And make them culpable.
The 8 million is based on Kaiser Permanente. But Kaiser will treat you for up to 100 days so mental conditions such as Schizophrenia is out.
For too long various governments tried to cut the cost on chronic care for the mentally ill to the point of not calling mental patients, patients but clients.
Yet the private sector is creaming off money from the NHS in mental health and other specialties.
The NHS is not being privatised, that won’t be much fun for the private sector. NHS must remain in name for the benefit of the private sector. They will make a profit or worst, pay their CEOs a high bonus.