Aneurin Bevan famously announced at the birth of the NHS that the sound of a dropped bedpan would be heard in Westminster. Over the past 60 years, we have lost something along the way. While it may be difficult for central policy-makers to be aware of every ‘dropped bedpan’ in our increasingly complex service, the failures of care so clearly and painfully detailed by Robert Francis in his report on the Mid Staffordshire NHS Foundation Trust were not even noticed and acted upon in the hospital within which they happened.1 Moreover, those of us working in trusts providing a high overall standard of care cannot be complacent. All of us are subject to the increasing strain on the NHS at the beginning of the 21st century – an apparently inexorable rise in emergency admissions, the increasing proportion of frail elderly inpatients with cognitive impairment and other comorbidities, and poor continuity of care and out-of-hours care breakdown – all set against a looming medical workforce crisis.2 Against this background the RCP set up the Future Hospital Commission (FHC), chaired by Sir Michael Rawlins. By now you will have seen at least some of its content referred to in the media and medical journals, including our ideas for restructuring the ‘front end’ of the hospital.3 However, there are two, less publicised, areas of our report that are worthy of particular focus – citizenship and integration.
Citizenship
The FHC used this term to reflect a broader responsibility than taking on the clinical care of an individual patient. It feels that physicians should also recognise a wider responsibility for the quality of basic care provided to patients throughout their working environment and take action whenever they become aware of inadequacies, regardless of whether the patient is ‘under their care’ or not. In short, the standard of care provided in any part of the hospital is the concern of everyone working within it; a responsibility extending beyond traditional ward or team boundaries. The FHC recommends that each trust should develop a charter in collaboration with its members and governors (foundation trusts), staff, patients and carers and community, to embed these principles and put them into practice.
In keeping with the RCP's previous work on medical professionalism (Doctors in Society),4 the FHC report underlines the partnership between patient and doctor based on mutual respect, individual responsibility and appropriate accountability. Doctors must be committed to integrity, compassion, altruism, continuous improvement, excellence and working in partnership with members of the wider healthcare team.
In practical terms, this means doctors must expect to provide clinical leadership for the whole care of the patient, working individually and at the system level. What we refer to as ‘whole care of patients’ covers all specialties, all settings and all domains of quality (eg safety, outcomes and experience). We must commit to communicating effectively with patients, their families and carers, where necessary being trained in relevant methods, including those relating to the diagnosis and management of dementia and delirium. Finally, we must work to collaborate with and empower patients, acquiring skills for shared decision making and encouraging better self-management by patients.
In these ways, consultant physicians can take back responsibility for medical inpatients – responsibility that was somehow lost in some hospitals due to the challenges described earlier.
Integration with the wider health economy
The FHC believes much more clinical care should be delivered in, or close to, the patient's home. Physicians should expect to spend part of their time working in the community, providing expert care integrated with primary, community and social care services, with a particular focus on optimising the care of patients with long-term conditions and preventing crises.
The FHC report recognises that no hospital can provide the range of services and expert staff needed to treat patients across the spectrum of all clinical conditions on a 7 day per week basis. New models of ‘hub and spoke’ hospital care need to be developed and coordinated across health economies centred on the needs of patients and communities, and based on the principle of collaboration, not just across health services but between primary, secondary and social care. It is likely that in many areas, large health economies will be served not by a number of district general or teaching hospitals, but by a smaller number of acute general hospitals hosting emergency departments and trauma services, acute medicine and acute surgery. These hospitals will be surrounded by intermediate ‘local general hospitals’ which, while not directly operating their own emergency department and acute admitting services on site, will contribute to step-down inpatient and outpatient care, diagnostic services and increasingly close integration with the community.
Conclusion
To some, the scale of these suggested changes will seem daunting. However, many of the ideas put forward by the FHC emerged from examples of good practice already being implemented by our fellows and members. Indeed, the FHC is grateful to the many physicians and their services for providing the case studies woven through the fabric of the report. The RCP urges fellows and members to read and digest the report, examining their own practice against its conclusions. The report is merely the end of the beginning and the RCP will make a formal response to its recommendations over the coming months, identifying areas that warrant further examination and research, up to and including the development of pilot projects designed to explore and evaluate the most promising ideas.
The time has never been better for us as physicians to take back control of standards of patient care, to develop our leadership skills and attune our ears to the sound of a dropped bedpan. If the sound reaches Westminster, we have failed.
- © 2013 Royal College of Physicians
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