News / News analysis: Tomorrow’s world

Last year, the Royal College of Physicians published a report
claiming the hospital system in this country was on the edge of catastrophe. The report, Hospitals on the edge, alarmed many, but perhaps its findings were lost in the subsequent uproar over the quality of care at some hospitals.

Now, the college has come back with ways of avoiding the crisis it predicted, and it is nothing less than a radical overhaul of the way clinicians deliver care inside and outside hospital. It would mean a significant shift in the internal structure of hospitals and fundamental change in how payments are made.

Future hospital: caring for medical patients set out 11 core principles of care, much of which is uncontroversial, including good communication with and about patients, services tailored to meet individuals’ needs and supporting staff to deliver safe, compassionate care. It also said patients should not be moved from ward to ward unless clinically necessary – care, including the clinicians who provide it, should go to the patient.

While few in the NHS would object to this, the RCP said a rethink of the clinical, managerial and financial structure of hospitals will be needed to deliver this change.

It is difficult to address the future of hospitals without paying heed to the seven-day service agenda. The RCP placed seven-day working in hospital and community at the core of its recommendations – services should be organised and integrated, with hospitals providing specialist medical services across the local health economy, including the community setting, it said. There should be greater continuity of care, with consultant presence on wards every day of the week.

To achieve this, it proposed bringing all medical services into a single medical division, headed by a chief of medicine. The division would include the emergency department, acute and intensive care beds and general and specialist wards.

An acute care hub would be part of the division and focus on the initial care and assessment of acutely ill medical patients – for example, in the emergency department, short-stay beds and intensive care.

Acutely ill medical patients would be cared for in the hub for up to 48 hours. A named consultant would coordinate care for a ward area within the division, while a clinical coordination centre would oversee data, feedback, team liaison and performance monitoring for services provided in hospital and the community.

Professor Tim Evans, lead fellow for the RCP Future Hospital Commission, which produced the report, said: ‘I hope this report will represent a template that can be adapted to the needs of patients in different geographical locations, and improve both their care and their medical management. We feel this will be achieved fully only where the hospital and wider healthcare facilities, including those related to primary and social care, are unified in their vision and integrated in its execution.’

Speaking on the Radio Four programme Costing the NHS in September, HFMA president Tony Whitfield praised the new report, saying it outlined a direction of travel for greater out-of-hospital care and improved services to patients. This could lead to economic benefits. Many trusts, including his own, were already engaged with their local health communities trying to make this happen.

Later he said: ‘We cannot afford to continue with the NHS as it is now. Services need to change and finance staff have a key role in supporting that change. The HFMA will be supporting members with the challenges ahead and help them ensure maximum value is gained from each £1 spent in the NHS.’

While the suggested structure sounds like ramped-up service line management – indeed, the report mentions the importance of SLM – HFMA immediate past president and chief executive of County Durham and Darlington NHS Foundation Trust Sue Jacques insisted it was more than that. She said the report’s recommendations could stop patients being passed around different hospital departments, as is sometimes the case.

‘I think it’s consistent with the seven-day service, in how we organise services around the patient, as Francis commits us to do,’ she said. ‘Patients would be centre stage to ensure consistency in terms of diagnostics and pathways.’

Another finance director was more sceptical, saying many trusts had a medical division, acute care hub and control centre, yet failed to meet A&E targets. He said the royal colleges had encouraged greater specialisation in recent years, making it more difficult to have enough general medical doctors. Often, specialist physicians did not cover general medical on-call. He was pleased that the report sought to reverse this by backing dual accreditation and the training of more general physicians, but the trick would be to convince the doctors.

Doctors’ contracts was another issued raised, and there has been potential progress on this in recent months. In July, NHS Employers and the British Medical Association announced they were beginning negotiations on a new junior doctors’ contract, while a similar announcement was made in September on the consultant contract.

While negotiations on the consultant contract will cover England and Northern Ireland only, the BMA said doctors wanted a more transparent pay system, and it strongly supported retaining the national contract. However, there was a willingness to increase out-of-hours consultant coverage for emergency and urgent care ‘if appropriately rewarded, resourced and implemented’.

The RCP report suggested new payment mechanisms were needed to underpin its proposals, highlighting the importance of the development work on year-of-care and pathway payment models.

It added that financial streams had to be realigned, not just to accommodate more hospital clinicians working in the community, but also to reflect the costs of providing acute medicine. It said this was often not the case for patients with comorbidities, as the complexity was not coded accurately – a particularly important issue as the population ages and the number of comorbidities rises.

University Hospitals Coventry and Warwickshire chief executive Andy Hardy said there would not be enough doctors to cover seven-day working in all hospitals. This would lead to some centralisation for emergency services, including medical emergencies. Tariff changes would be needed to fund services that will be required 24/7.

While the report said the complexity of some care is not always reflected in the tariff, Mr Hardy said trusts do not always code care accurately. ‘If they did so, that would lead to more information about the care of our patients and what needs to be funded and where they should be most appropriately treated.’

Ms Jacques said her trust currently operated on one block contract from commissioners. ‘It’s an experiment for us. The idea is that we have agreed with the CCGs to keep care out of hospital if we can. I have agreed to put payment by results to one side to generate something that’s more like the accountable care organisation model. I think we will see PBR for a bit longer, but we will find more organisations are trying to do things differently and use the freedoms under PBR more frequently – whether that be because of financial difficulties or, in organisations like ours, where we want to send a powerful signal to clinicians to do things differently.’

The RCP report has been almost universally welcomed. And, while most commentators say it is not controversial, they believe it sets out clearly what needs to be done to cope with an ageing population, many of them suffering from several chronic diseases, at a time when resources are constrained. As one finance director said, the report is not rocket science, but perhaps it’s caught the mood of the times.