The changing NHS: another attempt to treat more people away from hospitalsWhen NHS hospitals are full to overflowing, it may seem a case of upside down logic to call for them to be - in headline terms - 'shrunk'. But that is the call clearly implied in the NHS Long Term Plan that was issued in January.
The plan does not, of course, say in such plain language that major - or acute - hospitals will shrink. Their buildings will not be knocked down - it's their work that will be shrunk.
The Plan talks a lot about boosting 'out of hospital' care and 'relieving pressure on A&Es' and keeping older people at home for longer. To implement that, a major part of the Plan's extra funding will go to primary and community care.
Across England hospitals are operating at worryingly high levels of bed occupancy.
From April-June 2010 to April-June 2018 the level of general and acute bed occupancy rose from 86 per cent to 90 per cent. Such high levels put patient safety at risk (the optimum level of occupancy is put at 85 per cent) and can mean worsening A&E performances.
Wiltshire people are served - in the main - by three acute hospitals Salisbury, Royal United Hospital Bath (RUH) and Great Western Hospital (GWH). Wiltshire patients make up 68 per sent of Salisbury's total admissions and 43 per cent of the RUH's admissions.
GWH - which mostly serves Swindon - is the main acute hospital for patients from the Marlborough area and Wiltshire patients account for just 29 per sent of its total admissions. To take a day at random, on 28 February 2019 GWH's 494 beds were reinforced with 38 temporary beds - and bed occupancy was at 95.9 per cent.
Any talk of shrinking GWH would be ridiculous. The hospital has been overtaken by the huge and continuing growth in Swindon's population. Only recently has it been granted capital to expand - especially to expand its emergency/A&E department.
GWH's April Board Meeting was told about the increasing numbers of people coming to it emergency department. Once GWH's A&E doctors considered 240 patients attending the emergency department in a day as 'a busy day' and 260 patients as 'a really, really busy day.' But recently the have been seeing as many as 300 attendances in a day.
From the later years of Wiltshire's Primary Care Trust onwards there has already been a tilt away from treatment in hospitals towards treatment in the community. No one wants people to be in hospital and if they do have to be there, they want them out and home again as fast as possible. For older people especially, a long hospital stay can lead to a steep and general deterioration in health and wellbeing.
The GP-led CCGs, which hold the local budgets that fund acute hospitals, see their care as too expensive. But any comparative costings for community health services need to include the costs of social care back-up for those treated at home.
Hospitals are required to have an extensive and expensive infrastructure - including hugely costly equipment, highly trained and experienced staff and, for some, eye-watering annual payments for their PFI contracts.
As Primary Care Networks (PCNs) take over more of the more minor examinations, surgical; interventions and treatments, they will have also to take on duties now provided by hospitals - in effect a doubling up of cost and staff time. This may stretch a PCN's budget and staffing level - perhaps to breaking point.
Take for example child safeguarding. GWH's recent board meeting heard that between January 2017 and July 2018 there had been a 77 per cent increase in Swindon of children subject to a Child Protection Plan. These children require extra care and staffing in hospital.
Add to that the mandatory training for staff in safeguarding (some staff need a doubling in training hours) and "The impact on our safety team is dramatic." How will PCNs cope with child safeguarding requirements? Will PCNs have safeguarding teams?
Or look at another area that hospitals have to cope with: will PCNs have the resources to undertake planning for major incidents? Or will they still rely on the hospitals?
Hospitals are now paid on the basis of work done. Unless there is a sea change in the way hospitals are funded, when less complex work is taken away from them, the more complex work they are left with may well become ever more expensive.
It is also worth noting that despite the many millions of NHS pounds spent in recent years on the Better Care Fund/Plan to keep people out of hospital - treating them at home or 'in the community' - the hospitals are full and their waiting lists grow longer.
One of the problems facing all hospitals is the fluctuation in the number of patients needing consultations and treatment. They are not only at the mercy of the normal ebb and flow of referrals from GPs and seasonal variations.
At GWH it was thought that a sudden recent spike in referrals of patients with symptoms of possible breast cancer, could have been caused by a storyline in ITV's Cold Feet series. Revelations by celebrities about their cancer experiences can have the same kind of negative effect on waiting lists - although they may also have the positive affect of getting people talking about their conditions.
Similarly, could it be possible that a recent spike in A&E attendances at weekends has been caused by national media attention to the problem of concussion in contact sports?
Whatever the causes, hospitals have to find the staff and the beds to cope. And that takes us into the realm of the staffing crisis - subject of the next article in this series.
While many millions of NHS funds are being used to help out local authorities' dwindling social care budgets, in 2017-2018 England's 232 hospital trusts marked up a £991m overspend.
Unless there is a sea change in the way England's NHS hospitals are funded, it is more than likely that when less complex work is taken away from them, the costs of their more complex treatments and emergency admissions will rise - making another hole in the NHS budget.
This is the third in a series of articles on the new shape of the local NHS - following our introductory report of 28 March 2019. Next: NHS' workforce crisis - will it ever end?