How our absentee landlord lost the hospital plot
Authors: Mark Aitken
Journal: Journal of the Royal Society of Medicine (2010)

The Dr Foster1 database and the Healthcare Commission's reports are intended to keep hospital managers on the ball and give patients the opportunity to select or reject their local hospital's services. This is fine for non-emergency work because in theory these patients can choose where to go. Medical and surgical emergencies, which occupy >80% of hospital beds, do not have that choice. Their primary concern is the likelihood of death, but the data available to them is too vague to identify causal factors. Staffing levels, which are reported, bear little relation to excess mortality. However, the poor state of the fabric of our hospital buildings, which is not reported, does affect the motivation and morale of staff.

At the inception of the NHS the state acquired the freehold of a mixture of hospital real estate, ranging from dilapidated to smart, and in the process underwrote any outstanding debts. The voluntary hospitals, which were in effect owned by the local population whose generous donations had kept them afloat for decades, were given no mechanism to compensate their supporters. Since the overriding ethos behind the creation of the NHS was the delivery of free healthcare to all, losing the real estate seemed to be of little consequence.

Thereafter, the new hospital management boards received an annual allocation of funds which consisted of a large grant for day-to-day running expenses, and a small capital grant for buildings' maintenance and the purchase of new equipment. This was a complex arrangement with many idiosyncrasies. Where healthcare was delivered from multiple sites, the boards were encouraged to ‘rationalize’ in a bid to increase efficiency. Reducing running costs through the closure of the smaller peripheral units was the solution. In effect the outlying hospitals were asset-stripped and sold. The ‘beneficiaries’ of this process were supposed to be the national taxpayers. The local taxpayers, whose previous financial support had kept their hospitals alive, were left shouldering the consequences of having to rely on a vandalised service.

New buildings were paid for by the forfeiture of some of the family silver (the local residual real estate) and an annual levy given to the Exchequer. The trick was to hold on to your assets until the master plan had been signed and sealed (Norfolk and Norwich University Hospitals NHS Foundation Trust; Peterborough Hospitals NHS Foundation Trust), and not allow a succession of compromises to relieve you of all your assets before that vital deal had been done (Colchester Hospital University NHS Foundation Trust).

The next step to release Whitehall from its responsibilities was to encourage the private sector to fund new capital projects (PFI), and in so doing to pass ownership and any asset-strippable real estate to these consortia. The final coup de grace was to detach central government from custodianship by the creation of Foundation Hospital Trust status. This gave local healthcare to the manipulators of the money market where financial profitability out-trumps clinical excellence.

Where hospital trusts had followed Whitehall's piecemeal asset-stripping development formula, any new demands on accommodation could only be funded by operational profits. In that situation single-storey prefabricated buildings become the norm, but they have poor green credentials and their scattered distribution destroys clinical functionality. Our neighbours from Ipswich and Chelmsford have addressed the delivery of emergency care by substantial building programmes whereas Colchester has just littered its site with prefabs. One might surmise that the excessive mortality rate recorded for emergencies admitted to Colchester, as opposed to Ipswich or Chelmsford, is the legacy of its dysfunctional building programme.

Where has the medical profession featured while this creeping bureaucracy has taken over the guardianship of our patients' hospital care? Our best excuse might be that we have been sidetracked by trying to accommodate our commitment to duty of care and the imposition of the European Working Time Directive. Somehow we failed to see that these two challenges to the practice of medicine were incompatible. We then failed to remonstrate in a way that would stop the legislation in its tracks.

The politicians know that we are good material for manipulation by the time-honoured process of divide and rule. Our very diversities – from large specialties to small trail blazers; from gong gatherers to workaholics; from exhibitionists to recluses – are our Achilles' heels. The common factor, that we all deliver healthcare, is easily debased. Furthermore, specialization has created empires which we fiercely defend to the detriment of global patient care. The leaders of empire are easily distracted by power politics and lose sight of the profession's nobler attributes.

Today there can be no surprise that we find ourselves saddled with bureaucratic targets and a politicised concept of governance. Gone are the days when individual horizons were ambitious destinations not vote-rigging end-games and when conscience, not the clock, ruled service delivery. Rewards are being given to those specialties that generate the greatest profits, not the greatest good. Medical emergencies and those patients whose pathologies have failed to respond to the latest therapeutic mantras have to endure the landlord's dereliction of duty to provide the necessary hospital infrastructure. Clinical empathy might have come to the rescue of these patients, but is nowhere to be found.

This hospital Dutch auction has now gone full circle with Westminster's absentee landlord finally selling off the last of the dilapidated remains of their ill-gotten assets. Running a hospital like a factory will always disadvantage those who come to our doors through necessity and not through choice. Was it not this very principle of providing sympathetic sensitive care to those who could neither afford nor choose our services that underpinned the creation of the NHS?