Personal views: Painful decisions
Authors: Alice Bullen
Journal: BMJ (1998)

Tonight I have been reading a two page spread in my local newspaper about the threatened closure of the small community hospital that I work in. I was prompted to write by the comments of some of my patients and their relatives. 

I was appointed a consultant physician in a district general hospital 16 years ago. At that time the hospital abolished geriatric medicine as a separate specialty and all the general physicians agreed to implement a scheme of medical care where age was not a determining factor. We all had equal access to beds including rehabilitation beds in the hospital and this has worked well. Three of us, however, also have access to some beds in a nearby 44 bedded community hospital which over the years has treated many of my patients. 

This hospital caters for patients, mainly elderly, who are medically stable or whose illnesses are not amenable to acute medical care but who have continuing disabilities and rehabilitation needs. There are no resident doctors. The standard of nursing care and rehabilitation is excellent, as are the links with the community services. As the nurses do not admit emergencies the atmosphere and environment is geared to the special needs of the patients, who include many who can be cared for at home largely by virtue of regular treatment and by the regular relief offered to their carers. 

Because of the work of this small hospital many patients have been able to make wider choices about their future care and have been helped to accept necessary alterations in their lifestyle. The professionalism and skills of the staff are matched only by their kindness and commitment. 

Suddenly we hear that our health authority is drastically short of money and savings have to be made. The service is being scrutinised to see if it can be delivered more cheaply if the hospital is closed. The staff are uncertain about the future and many of the patients and relatives are anxious and upset. They are putting together a campaign to save the hospital; so far I have seen four lots of press cuttings, a petition, and tonight’s spread in the paper. The television cameras were there yesterday. 


What are my thoughts? It seems so unfair that a service whose evolution has been based on clinical need should be affected by a budgetary problem not directly related to the service itself. What do we mean by quality and audit and all the exhortations to seek to implement high standards, if such considerations cannot be quantified in the same way as a balance sheet and therefore do not have the same force? Is it more important to retain the service or go for closure and hope that a fragmented service elsewhere will deliver the same quality even when there can be no certainty about this or indeed about the ultimate saving? 


“I can only hope that ... they will not become some of the losers”



If this hospital closes there will be more pressure on district general hospital beds; less choice for patients; the re-emergence of bed blocking; an increase in the number of people going into permanent residential and nursing care; and a deterioration in the general medical service over the whole district. 

Similar considerations have been faced by many people. As they say, hard choices have to be made and there will be winners and losers. Looking at the words and pictures of my patients today, the people whose struggles and vulnerability I have seen and whose determination I have admired, I can only hope that we will be allowed the privilege of continuing to provide a high quality service to them, as they deserve, and they will not become some of the losers. I understand why policy makers who are driven by budgetary pressures dare not look too closely at the potential effects of their decisions on individuals; it might be too painful.