18 September 2011

Closing NHS hospitals

"Every year, demand for NHS health care – mainly from the greater number of older people – increases. Over the next five years it will grow by about 20 per cent, yet financing will increase by only one per cent. This is no longer viable."
The solution according to Paul Corrigan is to close hospitals. Yes. You read that correctly. The solution to 20% more old people needing more healthcare is to close hospitals - at least 40!

Dr Grumble would be the first to admit that the NHS estate needs rationalising and he would agree that the more you do of one thing the better you get at it but to imply, as Professor Corrigan does, that general hospitals should become specialist centres with one hospital doing one thing and another another is arrant nonsense.

Dr Grumble's masters used to teach him about the unifying diagnosis. The patient presents with various symptoms and signs and the key is to put them all together and find the single diagnosis that accounts for them all. It can work well. Previously fit young people who are acutely unwell are unlikely to have more than one thing wrong with them but it is not the case for the elderly.

It's no good being in a hospital that specialises in the treatment of heart disease and fancy ablation treatment for atrial fibrillation if your heart disease causes a stroke which is treated elsewhere. Or, if you are elderly and need a hip replacement, you do not really want to go to a slick privatised specialist hip replacement centre if you also have diabetes and heart failure as well as your arthritis. You need to be in a large general hospital where there is the right expertise available to cope with every contingency. You need specialist care for your hip but you may well also need specialist care for your heart and for your diabetes and any number of other possible complications. These scenarios are not unusual. In an increasingly elderly population they are the norm.

Paul Corrigan is right. Though he doesn't quite say so, the NHS estate is in a mess. The problem has remained, despite the NHS being a planned service, because politicians have always fought shy of any hospital closure. We can manage with fewer hospitals. But please lets not have small specialist hospitals with ring-fenced work. We need fewer but bigger strategically-placed hospitals with specialists doing sufficient work to do their jobs well with other specialists alongside them.

If demand is increasing by 20% over five years and financing by 1%, hospitals will have to close because there just won't be the money to pay for them. This is a financial solution forced on us by the marktet. But let's not kid ourselves that this is any sort of a solution to the clinical problems we face. What is to happen to all the increasing numbers of frail elderly people for whom there will simply be no hospital beds? Can they really be looked after in the community? Will this be any cheaper? Or does care in the community mean less care or, perhaps, no care?


Doctor Zorro said...

We are living too long, without any improvement in our quality of life, and there is an unaddressed gap between what we can do medically and what we should do compassionately. I am thinking of getting DNR tattooed across my chest in big letters.

Anonymous said...

My mother, a doctor, said she was going to do that in 1976 when she found out what I was doing in the then newish world of intensive care. She already had the insight to see what it might lead to. At the end of her life, knowing what she wanted, we had to make special arrangements to make sure she was not taken to hospital when the end came.

We do need better end of life care and planning. On the ward round I often ask the assembled multitude whether they would like to be kept alive if they were the patient before us. I have never yet had the answer that they would. So why are we keeping alive patients when we would not want to be kept alive if we were that patient?

Cockroach Catcher said...

You could not have put it better. Look a Monash, a huge hospital in Australia all the specialties in one place.

All he famous ones in the US from Mayo to Cleveland have all the specialists working together with no waste or the need to worry about who is paying for what as the doctors are paid a salary.

The trouble is as a friend's daughter that works at A & E said: 85% of those attending need not be there. What about the 15%? They all need expert care!

Planners want he 15% to be like the 85% but that is not true health care.

Why all the privitisation talk? In the end he rationing would be done by doctors too. The FTs would be doing more private work: for those on Insurance or from rich nations.

Closure of hospitals would be due to policies that lead to inequalities of income from the internal market. It is little wonder Circle would not want Stroke patients.

I have blogged a good deal as I felt that the majority of us go into medicine not primarily for the money(that would have been nice) but for some personal satisfaction which politicians fail to understand.

In the brave (or not so brave)new world, hospital doctors would still have the satisfaction of better pay, perhaps even better say but not so much of practising beter genuine medicine.

The NHS needs improving but not the way the ConDems are proposing.

Anonymouse said...

"you do not really want to go to a slick privatised specialist hip replacement centre if you also have diabetes and heart failure as well as your arthritis"

Shouldn't nature be allowed to take it's course in this case then? IMHO such elderly patient should be made comfortable at home instead of being subjected to yet more operations and more trauma, not only to save the cost of a hip operation that is unlikely to be money well spent but for the patient's dignity and well being, which is paramount.

In this case, nature is kinder than medicine, and it seems there are lots of these cases in the system.

Dr Grumble said...

A really painful hip precludes being kept 'comfortable at home'. Keeping the elderly comfortable at home may be appropriate but not for those needing a hip replacement. When it's bad you can't even sleep at night the pain is so bad.

What's more an elderly person who is immobile costs more not less because they can't look after themselves.

These things are not as simple as they may seem.

Dr Grumble said...

Charnley described his first hip replacement patients as ‘pitifully grateful’. Even now patients will tell you that life was not worth living before their hip replacement. Any risk of surgery patients in severe pain will see as worth taking.


Anonymouse said...

Point taken Dr G but I wasn't just talking about hip replacement but generally about procedures done for the elderly when it may be kinder to let nature do it's work. You posted about this yourself; that video of the Australian woman who was kept alive by force because her family didn't want to let go. You didn't like that yourself and I found it chilling - and cruel. I can't remember where this post is but you know what I mean

Dr Grumble said...

The point is a fair one; you just happened on the wrong example.

Julie said...

This is following a pattern that happened with hospitals up here, Dr G, with the same person at the helm, Dr David Kerr. The argument was that it would be better to have a few bigger specialist hospitals than a greater number of general hospitals. At the time that I was campaigning for Monklands hospital, there were 15 hospitals marked for downgrade across the central belt of Scotland. When the SNP got in, some of these decisions were reversed, but in Glasgow, several hospitals were shut and we are now going for a model where we have two level 3 hospitals, one north and one south and the rest are ACADs. It is not working; Glasgow Royal especially is overwhelmed and so is the Beatson, where cancer facilities are now being concentrated. I did feel that one of the HSCBs purposes was to close hospitals and it looks like it's happening.

Dr Grumble said...

There is a long-standing aim to close hospitals. I don't have any difficulty with that per se and in many ways it is long overdue. It may be that some care close to communities is necessary but you just cannot provide top class hospitals everywhere economically. Do you remember cottages hospitals? Low tech places where the elderly could recover from an admission to the high tech hospital or a place where they could go when they just need somewhere to be looked after for a while. But this is not what is on offer. What is on offer is just a net loss of hospital beds at a time when hospitals are bursting at the seams. We can't rationalise the NHS estate when we are in such straits.

What is the evidence to support these bed losses? In London we are told that we have far too many beds. But it is not actually true. It is just what the management consultants say based on some comparison with somewhere and the knowledge that they have to find some way of saving money and that the only way to do that is close beds.

Dr Grumble said...

OK. I have checked the figures. London has 3.46 beds per thousand people. The North East 4.13, the North West 3.47. The average for England is 3.18. The lowest is South Central at 2.54. So you can see how the management consultants think. But it doesn't mean that the North East has too many beds because they don't match the beds to the needs. They could be right but there are many reasons why somewhere like London with quite a different population to other parts of the country may well need the beds it has.

adifferentanonymous said...

"Shouldn't nature be allowed to take it's course in this case then?"

and in the case of children with a heart condition and diabetes, or a man in his thirties who's been in a car crash and can only be saved by traumatic (and expensive) operations? No? Why not?

At what age would you put DNR in a patient's notes?

Julie said...

I'm always intrigued to note how quickly discussion of the growing elderly population moves onto euthanasia.You'd think the two were connected.

Anonymouse said...

"At what age would you put DNR in a patient's notes?"

It's not about age, but about 'condition' - and I am not in a position to know when to include a DNR note because this is the doctors job and I am not one - but elderly or young, a patient should be allowed to die if medicine can not help anymore because nature is adamant to take it's course. Otherwise it becomes torture ... of an undeserving poor patient.

And this is not euthanasia Julie since it's not about helping a patient to die but about respecting that patient when it becomes clear that they are terminal and medicine can no longer cure or at least provide some quality of life. I wish Dr G would provide the link to his post about that Australian woman so that you can see what I mean.

Anonymous said...

I really don't think end of life care is about money. I have no problem with large sums of money being spent to give somebody, young or old, a life of quality. Of course if we all needed such care it would be unaffordable but fortunately we don't. We all contribute to the NHS as taxpayers. The lucky ones use it little, the unlucky ones get a lot of money spent on them.

Unfortunately what can happen is that large sums of money get spent on a patient and their body survives but their brain does not. These patients happen also to cost a lot to look after. If you knew this would be the outcome the treatment would not be indicated but you can't know the outcome when you institute the treatment. But the most upsetting thing is not the money that these patients cost but the poor outcome for them. If you could avoid such poor outcomes you would also save money. But if these issues were easy they would have been solved long ago.

Dr Grumble said...

Was this the video?

Anonymouse said...

Yes, this is the one Dr Grumble, thank you, if that is not torture, I don't know what is! The doc himself says that he would not want to be subjected to this 'treatment', I would like to join my voice to his.

Belinda Shale said...


This article may be of interest

Julie said...

"This is not about euthanasia"

Are you sure? Dr G mentioned the growing elderly population and how it was madness to reduce facilities at a time like this. Now the conversation could have gone two ways. We could have discussed raising health spending by 2% to come in line with other European nations. We could have talked about adding some more money to the lamentable amount that is currently spent on Alzheimers research to see if we could find a cure to it and enable people to live independently at home. We could have talked about bringing in spot checks in care homes to ensure that the elderly had a better quality of life. What we have talked about instead is that people are living too long. We have suggested withdrawing treatments such as hip replacements and allowing 'nature to take its course'. We have talked about getting DNR tattooed on our chests. In short, we have talked about every method we can think of, to shorten the patient's life, rather than what we can do to improve the quality of their life. And the worrying thing is, I'm not sure that you're even aware that you're doing it. Just because you don't use the e -word, doesn't mean that it's not there.

Old Codger said...

Care in the community means out of sight and out of mind. A good GP will fight to get the individual appropriate support but it is sometimes a losing battle.

I remember cottage hospitals, good things. About 60 years ago my father had a hernia repair in the local cottage hospital. Close to home, convenient and comfortable. Used to think my local, multipartner surgery might be developing into a modern version of the cottage hospital but it has now gone all commercial under a manager who has been to management school. Seems to have difficulty keeping new partners these days, more and more of the doctors are salaried.

Anonymouse said...

Julie, Euthanasia is actively taking part in ending someone else's life by one/more persons who have that predetermined goal and hence, work in collaboration towards achieving it. This is not the same as neglect, lack of provision, funds or research, although these too are essential elements for providing quality care to the sick and needy and you are right to insist on all of them being adequate.

Old Codger:

"Cottage hospitals"

A modern version was rejected outright by GPs, it was called 'Polyclinics'. Now, whether for financial reasons or for modernising and reform, it is inevitable many hospitals will close, what is there now to replace them and be the centre of that care in the community, and provide employment for the frontline staff who will become 'available' upon those closures too?

Old Codger said...


It was very early in the process when I thought my surgery might develop into something like a cottage hospital. If it had happened it would probably have been a gradual 'organic' process. They seemed to be taking on more minor procedures but it went into reverse when that partner retired. Mind it was around the time of Bliars interference so perhaps it was not all the next senior partner's fault.

Now the place is run by a manager nothing will happen unless there is significant profit from it.

Anonymouse said...

Thank you for the explanation Old Codger, I am not so much as worried about the involvement of the private sector, which will still be a small percentage of the whole when the bill becomes law, but rather about the vaccum hospital closures will create and the impact of that on patients and staff alike ... and on training the young doctors too.

the a&e charge nurse said...

"I'm always intrigued to note how quickly discussion of the growing elderly population moves onto euthanasia. You'd think the two were connected" - death is an inescapable part of the equation when we think about very old, very frail, demented patients with no ability to care for themselves.

Think about it this way - NHS staff would be unlikely to countenance a 30 bedded ITU run by a couple of nurses and HCAs - yet this is par for the course for most elderly care wards ....... why?
One thing's for sure - the gap between the rhetoric (oh, isn't terrible what happens to oldies in hospital) and the reality (patchy, and at time abysmal health care) has not not changed very much in my life time.

Maybe it's because good health care for such patients is labour intensive and ruinously expensive if the same standard was to be afforded to every bed bound, uncommunicative, and socially isolated person near the end of life?

A precursor to any sensible discussion about debilitated older patients should include quantifying the extent of their needs (which will include far more than just health care in many cases), setting standards, and then figuring how much it will all cost.

Perhaps one of the reasons such an approach has never been contemplated is because nobody really believes it would ever be attainable without doubling the % of GDP spent on health.

Julie said...

If we were just talking about the very old, very frail demented elderly, A&E nurse then it would be straightfoward. It is a judgement call in those cases whether to treat or not to treat. I know. I had to make those decisions for my mum. But the elderly are not simply made up of people at the very end of their lives. There are those who have all their wits, but might be physically incapacitated. There are those who are physically fit (like my mum was) but have dementia. And we are simply not dealing with this at all. We want them all to go away out of sight. We don't want to think about them or pay for them. I'm not looking for a doubling of health spending, although if we did, we'd then be spending the same as America does on health. I want to see things happening like investment in Alzheimer's research to find a cure. I would like to see a minimum nurse staffing requirement in elderly wards like they have in Australia and California. I would like to see some planning that doesn't look like it's been written on the back of an envelope for a growing elderly population. Because the fact is the oldies are there and they're not going away.

the a&e charge nurse said...

"I would like to see a minimum nurse staffing requirement in elderly wards like they have in Australia and California" - this would be a minimum first step in my opinion, and rather begs the question why on earth has it not already happened in the NHS? (coughs-money-coughs).

The problem of elderly care is compounded by the fact talking about dying, or the gradual loss of physical and psychological well being is still something of a cultural taboo - or it is a conversation left until very late in the day in many cases.

You may or may not remember a 5 episode Channel 4 documentary called "The Trust" (2002) - one scene depicted a hapless geriatrician talking to oldies about their resus status.
"Would you like us to try and start your heart if you have a cardiac arrest, Mrs Smith"?"
"Eh ..... am I about to die, doctor"?
"Oh, no, Mrs Smith, well I don't think so, but if you do what would you like us to do about it?"

It was one of the funniest and saddest things you could ever wish to see in part because oldies often regress, especially when confronted by the hideous combination of serious illness, and unfamiliar surroundings or language.

I saw this phenomena with my Dad (who had been a fairly astute and independent bod) and also my Mum when their time was nearly up.
Fact is (much as we may personally resent it) people who are past their sell by date are simply no longer valued in the wider culture - at least if we use action, rather than words as criteria for assessing the validity of such claims - I wish it were otherwise.

Anonymous said...

How about voluntary euthanasia like an advanced directive, when I am demented and cannot recognise my own family and have no quality of life please put me to sleep peacefully, permanently.

This will become socially acceptable and become legally allowable, but probably not in my lifetime!

Myalgic Muslimah said...

I agree with many of Julie's points. Whilst it is entirely fair to discuss the matter of quality of life, considering flicking the off switch rather than allowing someone to linger on in an horrific state etc, like Julie, I also felt uneasy by some of the things that were mentioned in the comments.

The example given was of a diabetic/heart disease sufferer patient needing a hip replacement and the next thing I know, someone talks about "letting nature take its course". I started to think of a number of my relatives and particularly my mum's diabetic brother, who is in his 70s, needed a quadruple bypass a couple of years ago, but aside from that is active and has a very good quality of life and many people of that age and generation are still productive members of society. If all he needed were a hip operation, my thoughts certainly wouldn't turn to "letting nature take its course".

It did look like the discussion was veering too much towards "the 'e' word" without actually saying it rather than discussing better quality of care, research etc.

Btw my sister refers to care in the community as "Don't care in the community" hehe.


the a&e charge nurse said...

Well, whether we like it or not, the NHS party is over.
In fact, 12 million patients may be watching rather anxiously to see how things pan out for the 60 hospitals affected the current PFI debacle?

"The reality is that all too often the marketisation of public services fails to produce value for money for either the public sector, or for the citizens who depend on the services. Meanwhile, far from saving the Government money, private finance increases the costs and exposes it to massive new risks of service failures, that the Government will have to step in and resolve. The marketisation of public services represents a failure of policy that increases the Government’s financial exposure and presents a potential personal catastrophe for vulnerable service users" - (p60).

In this current climate the bad things will increasingly affect oldies will probably be a result of omission rather than dastardly health workers trying to decide who is and who isn't entitled to another slice of the shrinking health cake?

Anonymous said...

cloud cookoo land stuff this

and so much emporers clothese stuff

for one people are euthenised every day in the nhs, nobody even healthy people can survice the "end stage" medications, sedate someone and up the pain relief and WITHDRAW ALL FLUIDS and anyone can and does die

i sat and watched a close relative being killed to the timetable decided by a nurse, not even a doc, sure he was terminally ill but he would certinly have lived more months if fluids had not been withdrawn

for 2 we dont even need a doctors signature before considering someone dead enough to put them in a fridge, sorry folk but when i pop my cloggs i think the docs owe me a casual once over before i go in the fridge, a nurses signature is NOT GOOD ENOUGH

moving onto compasion? lets set up an experiment an monitor how long it takes from patient asking for pain medicine to it actually being given to them in our general hospitals? if i was termanilly ill i would stay at home or go to hospice if for no other reason than not having to wait for an hour to get the morphine after the wave of pain hit

moving onto quality of life? i can tell matey boy below many diabetics get operations including hip replacement and go onto live happy and full lifes

personally i think the nhs stinks

we NEED the worst hospitals to shut, the public need to be allowed to take their business elsewhere

there is a natutal cycle which improves all businesses which is lacking in the mao style nhs, that is customers taking their business where they dam well like

grumble mate come with me for a few weeks i can show you how shit your precious nhs if for many patients, and i can show you many other western countries which do it so much better

nobody copies the nhs elsewhere because its crap, success breeds success and in the case of the nhs failure is there for all to see

Dr Grumble said...

Yours, Anonymous, would appear to be the view of the majority of MPs so I think you will soon have your way.

An interesting experiment may be about to take place. The NHS in England will be chopped up into lots of competing businesses while the old NHS may live on in Wales and Scotland. It will be interesting to see what happens. The new system will work as it does elsewhere but it will only be better than what we have now if it gets more money - which might happen as people are pressed into providing healthcare for themselves.

Purchasers and providers in healthcare are a very expensive way of doing things.

Anonymous said...

re "the old NHS may live on in Wales and Scotland" na its not

ive been out in the remote west of scotland and they aint happy there with the scot nats version of healthcare i can tell you for free

Anonymous said...

About this Dr G,


Where is the international community then?!

... or maybe they know, that's what you get when states mix religion and politics; weirdos! ... and people do suffer!

Dr Grumble said...

The king has let her off I am glad to report.

Anonymous said...

I wonder who is going to let the Palestinians off Dr G, a whole people, in millions, being lashed nonestop, and ethnically cleansed, while the world is not only just watching, but many are paying in support of the lashing too!

guilty commissioner said...

I was at a conference the other day and got into conversation with a commissioner in social care (my field). She seemed a lovely person and happily informed me that since she does not have a front line background ( e.g social work ) she was not troubled by "ethical stuff".

At the same conference I risked a comment that one council's commissioning plans for care home beds verged on the unlawful. I didnt actually see anyone roll their eyes but the irritation in the room at being reminded of old peoples' legal rights was palpable.

Dr Grumble said...

Lovely people without the ethos of professionals are becoming brainwashed by a system that cares only about the finances. They are preferred by the system because they don't have all that inhibiting baggage that we carry.

The saddest thing is the the professionals who should have higher ideals are being brainwashed too.

guiltycommissioner said...

Yes indeed, Dr G, even those of us who are prepared to stick our necks out can be seduced especially if we still want to be in our jobs in a year or so. As therapy I have started a blog guiltycommissioner at wordpress. howling at the moon maybe but it is better than sinking into depression.

Dr Grumble said...

For those of us who get upset at seeing madness all around us a blog can be very therapeutic.

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