Hospitals in England: Impact of the 1990 National Health Service Reforms

Author(s): Anthony J. Harrison

Source: Medical Care, Vol. 35, No. 10, Supplement: Hospital Restructuring in North America
and Europe: Patient Outcomes and Workforce Implications (Oct., 1997), pp. OS50-OS61
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MEDICAL CARE
Volume
35,
Number
10,
pp
OS50-OS61,
Supplement
?1997
Lippincott-Raven
Publishers
Hospitals
in
England
Impact
of the 1990 National Health Service Reforms
ANTHONY J. HARRISON
OBJECTIVES.
This article aims to describe recent
changes
in
English hospi-
tals,
with
particular
reference to the
impact
of the National Health Service
(NHS) and
Community
Care Act of 1990.
METHODS.
Significant policies
that have affected the
functioning
of the
hospital
sector of the British NHS are reviewed. Data from the NHS
Depart-
ment of Health are used to describe trends in utilization.
RESULTS. The NHS and
Community
Care Act of 1990
radically changed
the
financial and
organizational
framework within which
hospitals operate. By
creating separate purchasing organizations,
the act
opened
the
way
for com-
petition
between
hospitals.
In
practice,
such
competition
has been
very
lim-
ited. Central directives aimed at
reducing waiting
times for
nonurgent
admissions,
as well as at
raising
the volume of work done relative to the fi-
nances available have been more
significant
influences. These
changes,
com-
bined with
rising
numbers of
emergency
admissions,
have
put
the
physical
and human resources of
English
hospitals
under intense
pressure.
Admis-
sions have
risen,
lengths
of
stay
have fallen across all
age groups,
and ambu-
latory
care has
grown rapidly.
CONCLUSIONS. There is little consensus on the future direction
regarding
the role and structure of acute-care
hospitals.
There is
evidence,
though,
that
improvements
in the
process
and outcomes of care are
possible
within the
current financial and
organizational
framework of the
hospital
sector.
Key
words:
hospital policy; hospital
utilization,
hospital organization;
UK
health reforms. (Med
Care
1997;35:0S50-OS61)
The
English public hospital system
is cur-
rently
in a
phase
of
rapid
transition with the
introduction of health
policy
reforms that
bring
market incentives to a tax-based
pub-
lic
system
of health-care
financing.
This arti-
cle first
provides
historical
background
on
the evolution of the
English
hospital system.
It then summarizes the
implications
of the
1990 National Health Service
(NHS)
and
Community
Care Act for the
hospital
sector.
From the
King's
Fund
Policy
Institute, London,
Eng-
land.
Address
correspondence
to:
Anthony
J. Harrison,
King's
Fund
Policy
Institute,
11-13 Cavendish
Square,
London,
England,
WiMOAN.
Current
impacts
of the reforms on the
inpa-
tient arena are
discussed,
and
potential
fu-
ture trends
explored.
Considerable attention
is
given
to the status of efforts to monitor
quality
of care and
patient
health outcomes.
National Health Service and the Public
Hospital System Through
1990
The
English public hospital system
devel-
oped
out of the two
systems-the voluntary
and the local
authority systems-that
coex-
isted before the establishment of the NHS.1
In
1948,
Britain's
NHS,
a
centralized,
mostly
public, comprehensive
health-care
system,
was introduced and took these two
systems
OS50
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Vol.
35,
No.
10, Supplement
into
public ownership.
It was not until
1962,
however,
that a national
hospital develop-
ment
plan
was formulated that
sought
to or-
ganize hospital
services around local dis-
tricts. It was intended that each district
would have a
general hospital responsible
for
providing
the bulk of acute
hospital
serv-
ices to its local
population.
At the time of
this
system's inception,
each district's catch-
ment
population
was
100,000
to
150,000
people.2
The
implementation
of the district
system
led to a
program
of new
hospital building,
particularly
in
rapidly expanding
urban ar-
eas,
and to the consolidation of
existing
hos-
pitals
into
single
sites.
Large
numbers of
maternity hospitals
and
"single
service"
in-
stitutions were closed or their services
moved elsewhere. The allocation of re-
sources across districts for these
expansions,
however,
was
strongly
influenced
by
histori-
cal
patterns. Consequently, large
urban ar-
eas,
where the
major teaching
and research
institutions
resided,
continued to have an
ample supply
of services relative to other ar-
eas. It was not until 1976 that a
policy
of
equalizing
the financial resources available
to
hospitals according
to need was estab-
lished. In
keeping
with the decline in the ur-
ban
population,
which
began
in the
early
1970s,
a series of resource allocation formu-
las were created to
promote geographic eq-
uity
in the distribution of resources for hos-
pital
services.
Although
some elements of
the formulas remain
contentious,
the
gen-
eral
equalization objective
was uncon-
troversial.
Beginning
in the
1980s,
a series of
hospi-
tal reforms were enacted aimed at increas-
ing
their
efficiency: (1)
the introduction of
new
management
structures
designed
to
sharpen
internal
accountability
and decision
making, (2)
the
publication
of
performance
indicators,
and
(3)
the introduction of a
compulsory program
of
tendering
for ancil-
lary
services. A new
management
structure
replaced
the consensus or
tripartite
model
that had embodied three
separate
hierar-
chies-medicine,
nursing,
and administra-
tion. In this new
structure,
every department
ultimately reported
to the chief executive or
general manager.
Performance indicators
describing
the
inputs
and activities of
hospi-
tals were also introduced in the
early
1980s,
and included such items as
average length
of
stay,
annual
throughput per
bed, and
nurse
staffing per
1,000
patient-days.
And
finally,
a
program
of
compulsory competitive
tendering
for
support
services was
imple-
mented,
resulting
in
job
losses within some
areas of the
NHS,
and is
reported
to have
generated
substantial cost
savings.3
Yet
despite
the national framework for
ownership, financing,
and
reform,
the
Eng-
lish
hospital system
is
remarkably
diverse,
in
terms of the
range
of services
provided
and
the internal
organization
of care
delivery.
The
process
of consolidation into
single
sites,
which has been
taking place
since the
creation of the
NHS,
has
proceeded
at dif-
ferent rates in different
geographic
areas,
leaving
a number of
single specialty hospi-
tals
serving regional
or national markets. In
cities
large enough
to have more than one
hospital,
there
may
be some
degree
of
spe-
cialization between
them,
eg, only
one
may
provide pediatrics. Furthermore,
the older
teaching hospitals
tend to
provide
some
services over
large
catchment areas. Most
users of
hospital
services receive them in
their own district
or,
in London and other
large
cities,
in their own or a
neighboring
district,
traveling
further for some forms of
pediatric
care and
specialty
services
pro-
vided in
only
a small number of institutions.
Diversity
is also found in the
organization
of care
delivery-from
the
provision
of
emergency
services to
staffing
wards-
among English hospitals.
A series of studies
of
particular specialties
carried out
by
Robin
Dowie in the 1980s4 found a
large degree
of
variation in the
way
that work was
organ-
ized. More recent studies carried out
by
the
Audit Commission5'6-which
along
with
the National Audit Office is the external
auditor of the NHS for nonclinical matters
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HOSPITALS IN ENGLAND
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MEDICAL CARE
such as the
organization
and
management
issues-confirm that
diversity persists.
Sur-
prisingly,
there has been
remarkably
little
comparative study
on the merits of the dif-
ferent
patterns
of care
provision
seen.
The 1990
Hospital
Sector Reforms
The institutional framework within which
hospitals
functioned was
radically changed
by
the 1990 NHS and
Community
Care
Act.7'8 The act
fundamentally
altered the
roles of and
relationships
between the dis-
trict health authorities
(DHAs)
and
hospi-
tals.
Previously,
the
responsibility
for both
the
funding
and
provision
of
hospital
serv-
ices
belonged
to
approximately
190 DHAs.
The
responsibility
for
strategic management
and coordination of services resided with 14
regional
health authorities, each of whom
received an annual
budget
allocation for
hospital
services to be distributed
among
the DHAs in their
region.
Under the re-
formed
system,
the DHAs assume a
princi-
pal purchasing
role,
procuring hospital
serv-
ices to meet the needs of their local
populations
from
provider organizations
which
compete
to
provide
those services.9
These
provider organizations
consist of hos-
pital
and
community
health services estab-
lished as
self-governing
trusts.10
Nearly
250
trusts have a substantial acute
hospital
com-
ponent.
These reforms have created what
has been referred to as an "internal market,"
in which
providers
are
permitted
a
degree
of
competition
within the framework of a
pub-
licly funded
system,
with the goal of improv-
ing efficiency.7
In
addition,
the 1990 act allowed
general
practitioners
(GPs)
who met certain
require-
ments to become
general practice
fundhold-
ers,
who would also receive their own
budg-
ets to
purchase
some forms of elective
hospital
care.10 The role of GPs as
purchas-
ers has since
expanded greatly
both in terms
of
scope
of their
purchasing responsibilities
and the numbers who have become fund-
holders.1112
Approximately
half the
popula-
tion of
England
receives care in
fundholding
practices.
And as of
April
1997,
a number of
practices
have
begun piloting
the
purchase
of all forms of
hospital
care.
Virtually
all
hospitals,
acute and non-
acute,
psychiatric
and
nonpsychiatric,
are
now constituted as
trusts,
independent
of
the
day-to-day management
of the NHS.
Trusts own their
physical
assets,
contract di-
rectly
with the staff
they employ,
have their
own
accounts,
and maintain their own
gov-
erning
boards. The board of each trust con-
sists of five executives and six nonexecutives
usually
recruited from the local
community.
Financially,
trusts are
required
to make a 6%
return on their
assets,
and
although they
may
borrow to finance
capital
investments,
their
ability
to do so is
severely
circum-
scribed.
Managerially,
trusts are
largely
free
to determine their internal
organization
and
clinical structures.
The
language
of the 1990 act stressed the
ability
of district
purchasers
to commission
services
according
to local
needs,
and to
put
an end to
provider hegemony
in
dictating
care
practices.
In
fact,
the new
arrangements
have
yielded
mixed results. On the one
hand,
purchasers
have found it hard to im-
pose
themselves on
providers.
In most serv-
ice
areas,
DHAs lack the clinical and mana-
gerial expertise
needed for their new
role,
even
though
the
Department
of Health has
taken a number of
steps
to
strengthen
their
knowledge
base.13 On the other hand, GP
fundholders have been somewhat more suc-
cessful in
altering
the
way
that
hospitals
provide
services.
They
have
persuaded
some
hospital-based
consultants to see
patients
on GP
premises,
and have achieved
quicker
turnaround times for
laboratory
results at
hospitals by threatening
to use
private
firms
instead.
Still,
according
to the Audit Com-
mission
assessments,5'6
in most cases GP
fundholders are content with the status
quo,
and have not
changed
their referral
patterns.
Moreover,
their
power
to
change hospital
practices
is de facto limited in
many
cases,
because consolidation of services in
many
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HOSPITALS IN ENGLAND
parts
of the
country
has left them a limited
choice of
hospitals.
Proponents
of the 1990 act have
pointed
to the results of two
major Department
of
Health initiatives as evidence of the act's
success:
(1)
the
waiting
times
initiative,
and
(2)
the
purchaser efficiency
index. As
part
of
the 1990
reforms,
the
government
identified
long waiting
times for elective
procedures
as
reduction of one
goal
in its Patient's Char-
ter.*
Initially
funds were
targeted
to reduce
those lists on which waits were
particularly
long. Subsequently,
a
requirement
was im-
posed
on
hospitals by
the DHAs to continue
to reduce or eliminate
long waiting
times. As
shown in Table
1,
the initiative
appears
to
have been successful in
eliminating very
long waiting
times.
However,
the total num-
ber of
people waiting
for elective treatment
has remained at
approximately
1
million,
despite
a
higher
level of
hospital activity.
Furthermore,
these
figures
do not include
the
length
of time
people
wait to see a hos-
pital
consultant to be
put
on the
waiting
list.14 Indeed, it
may
be that GP referral
pat-
terns have
changed, responding
to the
per-
ceived
speed
at which a
patient
can be ex-
pected
to receive elective care.
The
purchaser efficiency
index initiative
focused on
improvements
in
hospital
out-
put,
as measured
by
the finished consultant
episode
or FCE. This measure differs from
one used
previously,
the
hospital stay
or ad-
mission,
which
may comprise
more than
one FCE if the clinical
responsibility
for one
patient
is
passed
from one
hospital
consult-
ant to another
during
a
single stay.
The total
number of
episodes
or FCEs is the unit of
measurement now
being
used to describe
*The Patient's Charter is the health services version of
the Citizen's
Charter,
which seeks to
implement
stand-
ards of services for most
public
services.
Specifically,
the
Patient Charter is a set of
rights
and standards for
patient
care
delivery.
It is
expected
that
providers
will be 100%
compliant
with the
rights
specified
in the
Charter,
and in
the course of time will be 100%
compliant
with the stand-
ards set therein.
TABLE 1.
Hospital Waiting
Times
1992 1995
Time
Waiting (months) (% total)
(%
total)
0-5 69.5 76.9
6-11 21.9 20.0
12-23 8.5 3.1
24 0.1 0.0
Total
waiting
(in thousands)
939.7
1,044.1
Note: From
Department
of Health.
hospital output.
Each
year,
a national
target
has been set for an increase in the number of
episodes provided.
This
target, currently
3%,
is translated
by
DHA
purchasers
into
targets
for
particular hospitals.
Strictly speaking,
this initiative has also
been successful. The number of FCEs have
risen
sharply
in recent
years.
However,
crit-
ics of this measure are
legion.
The unit of
measurement,
the
episode,
is
open
to ma-
nipulation.
For
example, changes
in ad-
mission
procedures may
increase the num-
ber of
episodes,
even
though
the treat-
ment offered and the number of
patients
remains the same. Not
surprisingly,
the ra-
tio of FCEs to admissions has risen stead-
ily
and varies from trust to trust. This rise
may
reflect
planned
readmissions or un-
planned
ones
resulting
from
patients
be-
ing discharged
too
early.
Or,
as
indicated,
it
may
reflect
changes
in
hospital organiza-
tion,
which
may
or
may
not
improve
effi-
ciency.
A third
policy
initiative should also be
mentioned. In
general, English hospitals
have been slow to introduce
day surgery,
but
spurred
on
by
an Audit Commission re-
port,15
the
government urged hospitals
to
increase the number of
procedures per-
formed in this manner.
Although
no na-
tional
targets
were
set,
many purchasers
set
targets
of their
own,
leading
to a
sharp
rise
in the
proportion
of total
surgical proce-
dures carried out in
outpatient settings
in
recent
years.
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MEDICAL CARE
These initiatives have combined to create
a turbulent financial environment for
hospi-
tals,
for
although hospitals
have continued
to
enjoy increasing
financial
resources,
re-
flecting continuing growth
in the NHS
budget
as a
whole,
they
have been
required
to
produce
with those monies
continuously
higher
levels of
activity, especially
the reduc-
tion of
waiting
times. Efforts to meet
activity
targets
have been
derailed,
in
part, by
growth
in the number of
patients
admitted
emergently
to
hospitals-currently, roughly
half the total admissions-numbers over
which
hospitals
have
virtually
no control.
This increase
cannot,
directly
at
least,
be
linked to
any policy
initiative,
and indeed
has been
largely unanticipated.
Further,
it
does not
appear
related to trends in
demog-
raphy
or in
morbidity,
and
despite
a number
of studies at the national or
hospital
level,
the
underlying
causes and their relative im-
portance
have
yet
to be established.16
Trends in
Hospital
Utilization
Changes
in
hospital
utilization evident
before the reforms are
continuing
in the
postreform
period.
Hospital
admissions
have increased
by
almost one third between
1984 and
1994,
from 1,336
to
1,767
per
10,000
population. Demographic changes
have
played
a minor role in the
growth
of
admissions,
with the bulk of the increase
caused
by rising
intervention
rates,
particu-
larly
in the
very young
and the
elderly.
Lengths
of
stay
have
concomitantly
fallen
across all
age
and
diagnostic groups
(Table
2),
and the overall decline is not caused sim-
ply by
the elimination of
very long stays.
The
net effect of the
growth
in admissions and
reductions in the
length
of
stay
has been a
decline in the total number of
inpatient days
of care.
Indeed,
although
the
average age
of
hospital
users has risen
(Table 3),
the share
of
inpatient
days
devoted to the
elderly
(ie,
older than 65
years
of
age)
has
changed very
little,
in
part
as a result of a notable decline
in
lengths
of
stay
for the
elderly. Day
case
TABLE 2.
Length
of
Stay:
Acute Admissionsa
Age (years)
1988-1989
(days)
1993-1994
(days)
All 6.6 5.4
0-4 3.7 3.1
5-14 3.2 2.5
15-44 4.0 3.4
45-64 7.5 5.7
65-74 9.9 7.5
75+ 13.3 9.7
aThese values reflect
lengths
of
stay
for finished con-
sultant
episodes (FCEs),
rather than for
patient
admis-
sions.
Note: From
Department
of Health.
(ie,
ambulatory)
rates have also risen
sharply
for the
period-from
176 to 499 cases
per
10,000
population-with
the
majority
of the
increase
occurring
since
1991,
likely engen-
dered
by
the Audit Commission
report
en-
couraging
the use of
day surgery.
The
impact
of these utilization trends are also seen in
measures of
hospital productivity,
such as the
steady
rise in the
hospital
sector's
cost-weighted
productivity
index shown in Table 4.
Since the 1990
reforms,
hospitals
have seen
a
significant
shift in the balance of their
work from
planned
or elective to
unplanned
or
emergent
admissions. In the
past, English
hospitals
have used
surgical
and
"long stay"
beds as a reserve to accommodate sudden
inflows of
patients,
as occurs in
periods
of
severe weather or
during
flu
epidemics.
The
rapid
reduction in
surgical inpatient
work
TABLE 3. Percent Distribution of
Admissions
by Age
Age
(yr)
1988-1989 1993-1994
0-4 16.2 14.1
5-14 6.7 6.0
15-44 30.1 28.3
45-64 21.4 22.8
65-74 13.2 15.1
75+ 12.4 13.7
Note: From
Department
of Health.
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35,
No.
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Supplement
TABLE 4. HCHS Cost
Weighted Activity
Index
Index 1983-1984 % Increase Over
Year
(100)
PreviousYear
1983-1984 100.0
1984-1985 103.0 3.0
1985-1986 105.7 2.7
1986-1987 107.3 1.5
1987-1988 109.1 1.6
1988-1989 110.0 0.9
1989-1990 112.4 2.2
1990-1991 113.9 1.3
1991-1992 119.8 5.2
1992-1993 123.6 3.1
1993-1994 128.5 4.0
Note: From
Department
of Health.
and in
lengths
of
stay
both for
surgery
and
medical care has reduced the available bed
reserves and the number of
patients
within
the
hospital
who
may
be
safely discharged
at short notice to release a bed. As a
result,
English hospitals
are
working
on
very
small
reserve
margins
with
occupancy
rates
around
90%,
leading
to a
sustained,
high-
intensity
work
pace.
Thus,
when sudden
surges
in admissions take
place, significant
pressure
is
imposed
on clinical staff and on
patients
who
may
have to wait before a bed
can be found.
The
hospital
is
becoming increasingly
fo-
cused on
diagnostic
and treatment
phases
in
which medical and technical contribution is
greatest,
and less on
recuperation
and reha-
bilitation
phases
in which the contribution
of nurses and
professionals
allied to medi-
cine
(eg, physiotherapy)
are
greatest.
Conse-
quently,
the number of medical staff and sci-
entific and technical staff rose 26% and
51%,
respectively,
between 1985 and 1994
(Table
5),
whereas
nursing
declined 14% almost
entirely
as a result of a reduction in the
number of students.17
Ancillary
and other
support
staff in
hospitals
have declined
by
more than
half,
largely
because of the con-
tracting policy
introduced
during
the
early
1980s.
The
increasing
use of doctors in
hospi-
tals has
required
an increase in their over-
all
supply
that the
government,
which ef-
fectively
controls
entry
into the
profes-
sion,
has been
prepared
to finance. How-
ever,
national
policies reducing junior
doctors' hours and
restructuring post-
graduate
medical
training
in
compliance
with
European
Union rules have dimin-
ished the
existing
labor force and made it
hard for
many hospitals
to
provide
24-
hour medical
coverage.
As a
result,
many
small
general hospitals
are
finding
it
hard to maintain a full
range
of clinical
services and are threatened with closure
or with the loss of facilities such as the
Accident &
Emergency (A&E)
depart-
ments
(emergency
rooms)
or
pediatrics.
These trends have led to
experimenta-
tion with
professional
roles and the trans-
fer of work done
by
doctors to other
pro-
fessions. The Doctors' Tale,5 the Audit
Commission's
study
of the use of
hospital
medical
staff,
notes several
examples
of the
new roles
emerging
(Table 6).1819
TABLE 5. National Health Service
Hospital
Staff
1985a 1994a %
Change
Medical
35,369 44,657
26
Scientific and
professional
9,518 14,393
51
Nursing/midwifery
352,273 306,992
-14
Ancillary
154,159 72,815
-53
aWhole-time
equivalents.
Note: From
Department
of Health.
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MEDICAL CARE
TABLE 6. Extract from The Doctors'Tale
Hospitals
differ in how tasks are divided between
junior
doctors and nurses or
other
professional groups.
In
many hospitals,
nurses and other
professionals
are
now
working
in areas that were
regarded traditionally
as the
province
of doc-
tors. These
changes
are the result
mainly
of
attempting
to reduce
junior
doctors'
hours of
work,
or of
responses
to difficulties encountered in
recruiting
doctors.
They
address
only part
of the skill
question;
the interface between
junior
doctors
and other
professions
...
* nurse
practitioners
in Accident and
Emergency departments,
and sometimes in
wards which
carry
out basic duties like
clerking patients (taking
a
patient's
personal
details and medical
history)
and insertion of intravenous
cannulae;
* clinical nurse
specialists,
who work
independently
but
according
to
guidelines
agreed
with
doctors,
have taken on some of the work
previously
done
by
doctors,
principally
in areas like intensive
care,
diabetes and care for the
terminally
ill;
* midwives who are
carrying
out the tasks of some
junior
doctors in
obstetrics;
* new
categories
of
support
workers like
phlebotomists
and
electrocardiogram
technicians;
and
*
non-medically
trained
surgeons'assistants
who have been trained to do
simple
operations
and
procedures, notably
in cardiac
surgery. They
work under direct
supervision
of a consultant who is
responsible
for their work. Their tasks
may
also include
assisting
the
surgeon
at
operations
and
clerking patients.
Source: Audit
Commission,
The
Doctors'Tale,
p.
18.
Quality
of Care and Patient Outcomes
Assessing
the full
impact
of
hospital
re-
forms
requires
information
beyond
the re-
ports
on
waiting
times and other standards
included in the Patient's Charter. Toward
that
end,
there are three main sources of in-
formation on the
quality
of the care
proc-
esses in
hospitals,
which
provide anony-
mous data on a
regular
basis:
(1)
The
National
Confidential Enquiry
into
Peri-Op-
erative
Deaths, (2)
The Audit
Commission,
and
(3)
The Clinical Standards
Advisory
Group.
The National
Confidential Enquiry
into
Peri-Operative
Deaths
(CEPOD),
which is run
by
the
Royal College
of
Surgeons,
has dur-
ing
the
years
identified instances of
poor
performance
in
surgical procedures
and the
factors associated with it.
Although
the
top-
ics covered in the
reports vary
from
year
to
year,
some themes such as the
importance
of
experienced
senior staff to the
provision
of
high quality
care are
perennial.
As shown in
an extract from a recent
report,
the
enquiry,
although
based on
specific
incidents,
aims to
derive
general
lessons for
application
in
acute
hospitals
(Table 7).
The second source of information is the
Audit Commission
reports.
The commission
began
as a
purely
financial auditor and it
still retains that role.
Yet,
its
general charge
to
investigate
the
efficiency
and effective-
ness of services has been flexible
enough
to
allow it to
report
on clinical issues as
well,
particularly
those around the
organization
of care. These
reports
have
typically
found a
great
deal of
diversity
in service
delivery
among hospitals,
as well as weaknesses in
internal
organization
and communications.
Finally,
the Clinical Standards
Advisory
Group
was established in
response
to fears
expressed by
the medical
profession
that fi-
nancial and
competitive pressures
that were
expected
to result from the 1990 act would
reduce the
quality
of care. The
Advisory
Group,
like the Audit
Commission,
takes
different areas of
hospital
work
and,
using
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HOSPITALS IN ENGLAND
TABLE 7. General Recommendations 1992/93
The National Confidential
Enquiry
into
Peri-operative
Deaths has
again
identi-
fied the substantial shortfall in critical care services.
Any hospital admitting
emergency patients,
and
hospitals admitting complex
elective
patients,
must
have
adequate
facilities for intensive and/or
high dependency
care at all times.
* Trainees with less than 3
years'training
in the
specialty
should not anesthetize or
operate
without
appropriate supervision.
* Practitioners must
recognize
their own limitations and not hesitate to consult a
more
appropriate colleague
when
managing
conditions outside their immediate
expertise.
* The skills of the
surgeon
and anesthetist should be
appropriate
for the
physiologic
and
pathologic
status of the
patient.
*
Surgeons operating laparoscopically
should not hesitate to convert to an
open
approach
when
necessary.
*
Appropriately
trained staff must
accompany
all
patients
with
life-threatening
conditions
during
transfer between and within
hospitals.
* The medical
profession
needs to
develop
and enforce standards of
practice
for the
management
of
many...
acute conditions
(eg,
head
injuries,
aortic
aneurysm,
colorectal
cancer,
gastrointestinal bleeding).
* There is an
urgent
need to
improve
the
quality
of medical notes.
*
Managers
need to
improve
the services
provided by
medical records
departments
so that notes are available when
required.
Source:
Report
of the National Confidential
Enquiry
into
Peri-operative
Deaths
1992/93.
Campling
EA,
et al. Confidential
enquiry
into
peri-operative
deaths
1992/93.
London,
1995.
the results of research conducted in a num-
ber of
hospitals,
draws conclusions about the
quality
of care
being
delivered. A recent
report
on
hospital management
of
emergent
and ur-
gent
admissions identified a number of ac-
tions
that,
it
might
be
thought, any moderately
well-run
hospital
would
already
have taken
(Table 8).
Although
these
regular reports
on
quality
process
measures are
available,
there is no rou-
tinely published
data on
patient
outcomes in
English hospitals.
There have been efforts to
publish
some statistical data on
hospital
care in
the NHS
through league
tables.20 Yet none of
the indicators in these tables relate to the out-
come, effectiveness,
or
appropriateness
of
care,
and instead focus
primarily
on
waiting
times for
elective
procedures.14'20
A number of clinical
outcome
indicators,
including hospital
death
rates,
are now
regularly published
in Scotland.
These
reports
are new initiatives
and,
as
such,
have been issued
cautiously,
and their data
should be
interpreted
with care. The NHS is
intending
to
publish
a limited set of indica-
tors on
hospital
care in
England
for 1997.
It is worth
noting
that the current set of in-
centives for
hospitals
embedded in the 1990 act
promote improvements
in
throughput
and vol-
ume rather than in
quality
or outcomes. It has
been
argued by
Bums21 that:
...trusts should be
paid by
clinical
results,
as
well as
episodes.
If,
on case mix
analysis,
it
seems reasonable to
expect
a certain defined
standard of clinical care and a trust falls short
of that
standard,
the trust should be
financially
penalised.
Poor outcomes should lead to a
poor
income for a trust. Clinical
performance
would then become at least as
important
as
financial
performance
to the trust and its
chief executive.
At the time of
writing,
no moves in this di-
rection are
apparent.
However,
a number of
initiatives have been undertaken that bear
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MEDICAL CARE
TABLE 8.
Summary
of Selected Recommendations of the
Clinical Standards
Advisory Group
on
Audit of
Urgent
and
Emergency
Admissions
Management
* Bed
ownership
and distribution
The move
away
from traditional "consultant
ownership"of
beds toward the
development
of more efficient schemes of bed
pooling
for
urgent
and
emergency
admissions,
including
reconsideration of bed closure
strategies
and
the function of "hostel"or "hotel"beds.
*
Urgent/emergency
services
organization
Operational
research on the
optimal organization
of admission and/or observation
wards.
Urgent
move to
provide
24-hour
availability
of
emergency
theaters.
* Clinical directorates-communication and
management
The further
development
of clinical directorates to ensure the full and
continuing
collaboration of
managers
and clinicians in use of resources for
emergency
services.
*
Staffing
Review of
nursing
and other
professional staffing
and distribution to meet needs.
*
Availability
of
support
services
Audit of
diagnostic
and other
supporting
services to
identify
shortfalls and
delays.
*
Discharge planning
The
appointment
of
discharge
coordinators.
* Information
technology-intrahospital
communications
Exploration
of
potential
uses of information
technology
to facilitate the
rapid
transfer of relevant information
(ie,
results of
diagnostic tests)
and
improve
communication with consultants on call.
Source: Clinical Standards
Advisory Group, "Urgent
and
emergency
admissions
to
hospital."
Clinical Standards
Advisory
Committee.
Urgent
and
emergency
ad-
missions to
hospital.
London: Her
Majesty's Stationery
Office,
1995.
directly
on the
quality
of care
hospitals
offer.
The 1990 act mandated clinical audits
covering
the work of
doctors, nurses,
and other
profes-
sionals,
though
the results of these reviews are
not
published.
A broader initiative in the area of
outcomes has been the
promotion
of "evidence-
based
practice."The Department
of Health has
supported
a
range
of
activities,
including
struc-
tured research and
development programs,
in-
formation
bulletins,
and
university-based
cen-
ters
specifically
devoted to the assessment of
evidence related to the effectiveness of inter-
ventions. The information
produced through
such
endeavors,
it is
hoped,
will facilitate better
purchasing
decisions
by
DHAs and GP fund-
holders for their
patient populations.
In addition to these
patient-level
care effec-
tiveness
studies,
a number of recent
reports
have
begun
to look at the
organization
of care
and the merits of different forms of
organizing
hospitals
and associated services. For exam-
ple,
the
Department
of Health
recently ap-
pointed
an
expert
committee to review cancer
services,
which recommended
establishing
a
network of
hospital-based
cancer centers
with
appropriate support
services in other
hospitals
and in the
community.
Similar re-
views have been carried out in
London,
questioning
the
proliferation
of small
spe-
cialist units across all
teaching hospitals,
rather than
concentrating
these services
more
selectively.
Such studies can be useful
in
effecting
the
organization
of care at the
level of the individual
hospital,
as well as for
the
population
as a whole.
Future
Developments
There are no
official,
or even
generally
ac-
cepted,
forecasts of the future
activity
level
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in
hospitals,
and the net effect of current
trends is less than clear.
Indeed,
there is little
doubt that some
existing hospital
services
could take
place
in smaller
institutions,
such
as
community hospitals, general practitio-
ners'
premises,
or
patients'
own homes. A
number of
initiatives,
taken
by general prac-
titioners and those trusts
providing
commu-
nity
health
services,
have resulted in the
transfer of
simpler
medical
procedures
and
nursing
and allied
professional
services for
postacute
care to
noninpatient settings.
Yet,
although
there has been a
great
deal
of small-scale
experimentation
in
shifting
hospital
services,
larger-scale change
has
been hard to achieve. In
principle,
it was
thought
that district health
purchasers
would be in a
position
to effect such
shifts,
but in
practice they
have failed to do so. The
task of
keeping hospitals
in line with na-
tional
performance targets
has absorbed all
their
managerial capacity.
If
budgetary
con-
trol continues to be shifted to GP fundhold-
ers,
and if
budgets
for
primary
and secon-
dary
care are
merged (they
now form two
distinct cash
streams),
then the incentives
for
shifting
care
away
from
hospitals
will be
increased.
Other
budgetary changes
could also affect
hospital activity
in the future. For
example,
increased
funding
for
geriatric community
services could reduce
emergency
admissions
for the
elderly
who wind
up
in
hospitals
be-
cause of lack of alternatives. Another
poten-
tial
strategy
is the
development
of
patient
management regimes
in which the
hospi-
tal's role would
comprise diagnosis
and de-
cision
making,
with the treatment
provided
in a
separate
location. This
may
mean,
for
example,
that instead of treatment in the
hospital,
the
patient
is referred back to a
community-based professional. Develop-
ments like these will be aided
by
informa-
tion
technology,
which allows real-time ac-
cess to
hospital-based expertise.
There are
several small-scale
examples
of this in
Eng-
land,
eg,
minor
injuries
clinics linked to
larger emergency departments.
One trend that can be
expected
to con-
tinue is the
increasing specialization
in
medicine and
nursing.
The main factor
lying
behind
specialization
in the
past
has been
the
rapid growth
in clinical
knowledge,
leading
to the subdivision of
general
medi-
cine and
general surgery
into a series of
separate specialties.
However,
further
spe-
cialization
unaccompanied by
innovation in
working practices
will have serious
implica-
tions for the structure of the
English hospital
system,
for if the basic
concept
of the district
general hospital
is
maintained,
then the size
of the
hospital
will have to
grow.
The notion
of a
general hospital serving
its local
popu-
lation for
nearly
all their needs
may
be
gradually
abandoned in areas that cannot
support
the full
range
of medical or
surgical
specialties.
A district
general hospital
in a
sizable
free-standing
town
might
now meet
95% or even more of its
population's
need
for
hospital
care. But if
specialization
contin-
ues
further,
then such
hospitals
will have to
begin "trading"
with one
taking
over all
pe-
diatric
care,
for
example,
while another takes
over all
specialist
cancer care
(or
within can-
cer
itself,
different
hospitals might specialize
in different
sites).
This form of
trading
is al-
ready
common between smaller
hospitals
in
adjacent
towns or within
metropolitan
ar-
eas. Further
specialization
would
imply
that
most
hospitals
would have to work on this
basis.
Conclusion
The
English hospital system
continues to
be
perceived by
those
working
in it as
being
under continuous
pressure. Waiting
lists
persist,
and
despite
the extra
activity
in the
past
few
years
the numbers
waiting
have not
declined.
High occupancy
levels have re-
sulted in
widely reported queues
for
beds,
and in some cases
hospitals
have refused to
admit local
patients
who have had to be
transferred to other more distant
hospitals.
Many
medical
specialties
are in short
supply,
leading
some
hospitals
to
import experi-
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MEDICAL CARE
enced staff from other
countries,
including
Western
Europe,
North
America,
and South
Africa. There is a
suspicion
that
lengths
of
stay
have been cut in an
unplanned way
to
save
hospital
costs,
even where the commu-
nity
costs,
eg,
of home-based
care,
may
be
higher.
The
pressures
described here have stimu-
lated a number of
changes. They
have,
for
instance,
created incentives to
reorganize
the flow of
hospital
work
particularly
in re-
spect
to the treatment of
emergency pa-
tients,
eg,
the introduction of admission or
observation wards.
They
have also stimu-
lated
experiments
in skill
mix,
including
the
substitution of
nursing
for medical
staff,
particularly
in some of the
shortage
areas,
as
well as the
development
of
specialist
nurses
to
complement specialist physicians.
Currently,
there is no consensus view of
where these
pressures
will
lead,22
and con-
flicting
views on what the role and structure
of acute-care
hospitals
should be. For exam-
ple, although
some
urge
further
hospital
closures and the creation of
regional super-
hospitals serving perhaps
2 million
people,23
others24
argue
that most of what is
currently
done in acute-care
hospitals
can be dis-
persed
to
community settings,
and still oth-
ers
argue
for
preservation
of the status
quo.25
Further concentration of services in
large hospitals
would create incentives to
shift additional care to other
settings by
ex-
tending
the role of smaller subacute com-
munity hospitals
or home-based
services,
thereby assuring adequate
access to
hospital
services for the catchment
population.
This
approach
is
used,
for
example,
in Oxford-
shire,
with the acute-care
hospitals
in Ox-
ford itself
discharging patients
to smaller
hospitals
in the towns in the
surrounding
county.
This
pattern
has
yet
to be found in
London,
where there is no
parallel system
of
small
hospitals,
or in
many
other
parts
of the
country
where such
hospitals
have been
closed.
There are
signs26
that
hospitals
are re-
thinking
the
organization
of clinical work
both in
respect
to
planned
and
emergency
activity.
But it is
arguable
that the main is-
sues to be tackled lie in the financial and or-
ganizational
framework within which
Eng-
lish
hospitals
work. As it
stands,
the current
framework
provides
clear incentives to in-
crease
activity,
but no clear evidence of the
benefits of
doing
so.
Indeed,
many
of the
failings
identified
by
CEPOD and
by
the
Audit Commission
appear
to stem from the
way
resources are
deployed
within
hospitals,
rather than from their low absolute level.
Improvement
in the
process
and outcomes
of care should become a
priority
for
pur-
chasers and
providers
of
hospital
services,
and
ought
to be attainable even in a health-
care
system
that
makes,
relative to those in
other advanced
countries,
modest calls on
the nation's resources.
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