Last week Monitor announced that it intends to conduct an investigation into the ‘challenges’ faced by half the NHS and Foundation Trusts in the country - the smaller half - in their efforts to provide high quality and sustainable care. The health service regulator will be asking for views from patients, providers, commissioners, healthcare professionals and ‘other interested parties’.
Monitor mentions that 'it does not wish to pre-empt the outcome' of its investigation. But why did Monitor feel the need to say that?
Perhaps we should be reassured. In August 2007 David Cameron himself promised a "bare knuckle fight" to defend District General Hospitals against then Prime Minister Gordon Brown.
Even in the 'neoliberal landscape', there is a coherent economic argument that smaller hospitals can be more flexible, nimble and resilient in coping with the economic challenges of the NHS, as elegantly described in this recent Health Services Journal article.
But there are reasons why one cannot be reassured about what is happening.
We all remember David Cameron’s “no more top down reorganisations” pledge at the Royal College of Nursing Congress.
The recent mood music hasn't been great - particularly for smaller hospitals whose financial model makes obtaining now compulsory Foundation Trust status difficult. For example in their pamphlet, “Dealing with financially unstable providers”, the King's Fund stated that:
For a competitive market to work, it is argued that there must be consequences for inefficient providers and those who do not attract patients. Again, this requires a mechanism by which providers that lose business are allowed to fail and exit the market.
The government is currently attempting to change the law to allow more widespread fast-track hospital closures, through a Clause in the Care Bill that extends of the powers of the Trust Special Administrator. The amendment, currently before the Commons, has met with widespread opposition.
Whilst Lewisham Hospital won its landmark fight at the Court of Appeal against the Secretary of State for Health this week, it has just been announced that two accident and emergency (A&E) units in smaller London hospitals are to be downgraded.
Fundamentally, the problem here is one of equitable access to healthcare in the NHS.
Suppose I offered you a choice between a carton of milk in your local corner shop which you can easily walk to, or from a supermarket five miles away. You can only get to the supermarket by getting in the car. It’s the same carton of milk. Which shop do you prefer?
Smaller hospitals, including District General Hospitals, are still populated by Doctors there with at least ten years of medical training under the belt. So the idea that they are offering a second-rate service for the common medical emergencies is a fraudulent one.
Sure, it is possible to frame an argument that you can deliver a 'mega hospital' a bit like a 'mega dairy', but the argument that 'big is more efficient’ is not proven.
We will always need Doctors, nursing and allied health professional teams to deal with the 'bread-and-butter' of acute medical conditions. People suffering chest pain, acute shortness of breath (including acute severe asthma), acute exacerbation of an inflammatory bowel disease, an acute pneumonia, an acute headache, and so on.
Patients, understandably, wish to get to a local hospital without any fuss, and to be set on course for the correct treatment. They can of course be referred onto specialist centres if need be (for example an acute headache might be a bleed in the brain which requires neurosurgical evacuation.)
Even people who understand markets appreciate that the market is 'segmented'. It is impossible to address the needs of your 'customers', unless you understand what groups of customers desire.
The essential management of most acute medical emergencies is the same whether or not you happen to be in a district hospital or a large teaching hospital. This is because there is an acceptable standard of treatment of what clinicians would do for patient safety reasons.
For example, if you’re having an acute severe asthma attack, you are almost certainly going to have your treatment as described here on p.62 onwards of the British Thoracic Guidelines on asthma.
The issues about 'access to medicine' are complex. They are also hugely relevant to what sort of society we want. It would be a grave error to ignore the views of professionals such as Dr Jonathon Tomlinson, who for example here in the London Review of Books describes a typical surgery of his and the need for accessible local care.
The Monitor inquiry into smaller hospitals feels like an undertaker doing a ward round on the intensive care unit.