Reconfiguring acute hospitals in England
Authors: Chris Ham
Journal: BMJ (2006)

The financial pressures facing the national health service (NHS) in England, coupled with changes in medical practice, are raising fundamental questions about the current configuration of acute hospitals. With some services being provided in people's homes and in primary care, and others being concentrated in specialist centres, the viability of the current network of district general hospitals is in doubt. 

If the closure of entire hospitals is likely to be the exception rather than the rule, many hospitals will have to reduce the range of services they provide to adjust to changes in their environment. This was acknowledged by David Nicholson, the newly appointed NHS chief executive, in a recent letter to MPs in which he emphasised, “Our aim should not … be to preserve the status quo, but to think imaginatively about how we can unlock the resources, both in terms of money and people, to re-direct them where most benefit can be achieved for patients.” 

As Nicholson's letter makes clear, hospitals have been affected by long term changes in how health care is provided to patients. These changes centre on increases in day case procedures, reductions in lengths of stay in hospital, and an expansion of the work undertaken outside hospitals; for example, in the management of chronic disease. The net effect has been to reduce the need for beds in acute hospitals by enabling care to be delivered in other settings, thereby raising questions about the current organisation of services.1

The challenge this creates is how to persuade MPs and the public that changes in hospital configuration are desirable when they entail reduced access to some specialist services. This is illustrated by events at Kidderminster Hospital in the late 1990s when its accident and emergency service was closed and it was used mainly as an ambulatory surgical centre. 

Opposition to these changes at Kidderminster was led by a local general practitioner, and the local Labour MP lost the 2001 general election as a result of the campaign. The loss of this parliamentary seat by the Labour party exemplifies the political risks of promoting reforms that affect the public's access to health care. 

This lesson has not been lost on the government, which now handles changes to the role of NHS hospitals more carefully. An independent reconfiguration panel has been established to advise on such changes. Moreover, Sir Ian Carruthers, until recently acting NHS chief executive, will work with health authorities on proposals for service reconfiguration. 

Much of Sir Ian's time is likely to be spent ensuring that the NHS takes a strategic approach to change and follows rigorous and fair decision making processes. This includes engaging stakeholders such as local authorities and the public as early as possible, and allowing sufficient time for other options to be considered. 

Experience has shown that it is essential to involve clinicians in hospitals and primary care in work on reconfiguration and to secure their commitment to change. The NHS should also make it clear why change is needed and articulate a persuasive and reasoned case to support proposals that are bound to be controversial. Failure to do so may mean that changes designed to improve the quality of care may be blocked. 

In many cases reconfiguration will probably require hospitals to collaborate with each other to ensure that the public has access to a full range of specialist services on different sites. Tension exists between the need for collaboration to agree on the appropriate location of specialist services and the expectation that hospitals will compete for patients in the evolving programme of health reform in England. 

In this respect, government policies have accentuated the challenges presented by long term changes in service provision.2 Where hospitals are run by separate organisations competing for income in the healthcare market, duplication of services may occur on adjacent sites, and quality of care may suffer. 

The government may need to review its own policies to enable necessary reconfigurations to occur. Bringing about improvements in care for patients and the public will not be achieved simply through the invisible hand of the market, despite the dominance of market based thinking in government. 

In this context, the virtues of service planning should not be forgotten, particularly in dealing with hospitals that get into difficulty and in ensuring that services are concentrated in fewer centres if this improves outcomes. Recognising the need for a planned market in health care, if this is not an oxymoron, should loom large in the next iteration of health reform.