Care closer to home is not what the NHS needs
Editor – Linda Patterson's editorial claims that ‘More community working should lead to better management of chronic disease. This is the future’ (Clin Med February 2010 pp 4–5). I hope not. I think it is regrettable that the ‘care closer to home’ mantra has somehow hypnotised us into presupposing the existence of some physical (or maybe metaphysical) barrier between hospital and community, with prejudices reinforced by inflammatory language.1 Policy it may be, but if it is bad policy we should have nothing to do with it.
At a time of economic crisis in the NHS we must husband resources. Small shops, while convenient for their users, are inefficient, as supermarket analysis proves. The network of community hospitals that sustained the NHS until the 1980s was largely closed down because it was unaffordable. To recreate it with new community hospitals or polysystems at huge capital cost (not least if projects require large private finance initiative repayments) is madness. What may be more convenient for some service users may be less convenient for others, as became apparent with a proposed network of musculoskeletal independent treatment centres in northwest England.2 The idiocy of the approach is exemplified by one of my patients who, told by their general practitioner (GP) that the community service was more convenient (because it was in the community), pointed out that it was two bus rides away when the district hospital was within five minutes’ walk. If patients have to travel to another general practice where the specialist does clinics what difference is it to travelling to the hospital? Except in widely dispersed rural districts there is none. Gains to patients of local access to specialists may be largely offset by the inconvenience of multiple appointments because investigations such as X-rays cannot be organised ‘in the community’ on a one-stop basis.
We have become so focused on the public getting what they think they want that we have forgotten the needs of services and those who work in them. Why should I waste an hour a day travelling between under-resourced sites, thus reducing the number of patients I can see? I did outreach clinics in GP surgeries in the 1980s and abandoned them because they did not work. How will my multidisciplinary teams accompany me without a team bus? What about my inpatients and those I will not be able to see for my colleagues as I am no longer on the hospital site? How will I discuss cases with others, and they with me? If I am speeding around the community doing rheumatology clinics, how can I manage my rehabilitation unit? Multi-tasking is possible on one site, but not on many. Trainee teaching will collapse as the diversity of case-mix, a virtue of service concentration, will be lost. The opportunity to collect cases for clinical trials will dissipate. Departmental morale will collapse. A two-tier service of superspecialist care in big teaching centres and barefoot specialist care elsewhere will develop. These are not my arguments alone; I asked my chronic disease ‘focus group’ (our local National Rheumatoid Arthritis Society network group) whether they would prefer to be seen by me in the hospital clinic or in their own GP surgeries. Without exception they expressed a preference to be seen at the hospital, citing many of the above concerns. Ask the wrong people and you get the wrong answer.
Concentration brings benefits. The clearest example of this is surgical; in the first world war facial injury care for Great Britain and the Dominions was concentrated in one hospital (mine, as it happens) and the advances in plastic surgery thereby generated were unmatched on the continent where facial injury was dealt with in a fragmented way. Furthermore the patient support that grew from this obviated the need for a self-help group, whereas in France ‘les gueules cassées’ developed because of the isolation and dispersion of sufferers.3 To create a specialist diaspora will recreate the disadvantages of dilution. We must learn from history.
Lastly, Care in the Community often means very little, or no, care. As social service budgets contract and input from carers diminishes we have already seen the adverse effects and must do everything we can to avoid this in medicine.
That is not to say that hospital-based care is cheap or that we should not look for ways of making it cheaper, for example by running telephone clinics for those on long-term follow-up. As Patterson points out, hospitals are encouraged to maximise income, while PCTs try to limit access because Payment by Results (PbR) tariffs are unaffordable. But we do not need to disperse specialists to address this; as the musculoskeletal services in Stoke and Bolton have shown it may be possible to avoid substantial transactional costs by changing management from acute trust to PCT without necessarily altering the physical structure of the service. We should also remember that those services turning a profit in an acute trust (rheumatology outpatients is one) will prop up the loss leaders (acute medicine is one). So pulling out profitable services may compromise the whole of acute hospital-based care – unless the purchaser–provider split is abolished, which, for me, would be the essential and final outcome of Teams without Walls.4
I firmly believe that care closer to home is a concept based on flawed research and the turning of a blind eye to economic reality. Specialist medicine as a whole will be seriously damaged if we fail to examine its risks.
Footnotes
Please submit letters for the Editor's consideration within three weeks of receipt of the Journal. Letters should ideally be limited to 350 words, and sent by email to: Clinicalmedicine{at}rcplondon.ac.uk
- © 2010 Royal College of Physicians
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