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LETTERS: Paul V Knight Is the NHS guilty of ageism by not giving free personal care for some older people in England? BMJ 2001; 323: 337 [Full text]

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How best to organise acute hospital services?

Brian Harrison   (15 August 2001)

How best to organise acute hospital services? 15 August 2001
Brian Harrison, Consultant Physician Norfolk Send response to journal: Re: How best to organise acute hospital services?	Dear Editor How best to organise acute hospital services? We are responding to the Editorial on this subject1 as two consultants who work in the acute front line hospital services. Current proposals commend hospitals and networks serving populations of 500,0002. Dr Smith writes that the evidence that hospitals serving populations of 500,000 are necessary to ensure high quality care, is moderate for some surgical services but unclear for medical services. There is, in fact, very clear evidence in the surgical and oncological literature that there are better outcomes across the range of malignant diseases when patients are looked after by specialist teams rather than generalists. Similar evidence applies to joint replacement, treatment of fractured neck of femur, urological conditions and vascular surgery. However, it is the problem of medical emergencies that looms large in most acute general hospitals in Britain, and it was in dealing with these that Andy Black presented his model in which patients would first be admitted to a local small hospital which would, in effect, be an assessment arm of the big hospital. Studies in the last ten years across the range of medical emergencies have shown better care in terms of process and outcome for asthma (six studies eg3), gastrointestinal haemorrhage (four studies eg4), ischaemic heart disease (three studies eg5), stroke, and rehabilitation in acutely ill elderly patients. Delay in implementing optimal management in such conditions can affect outcome. However, it is not only better outcomes that specialist teams achieve, it is more precise diagnosis. In the respiratory field in our hospital it is an almost daily occurrence for patients with COPD or the hyperventilation syndrome to be misdiagnosed as having asthma. Were they not transferred to the specialist team they would receive inappropriate management and unnecessary medication. In the present state of health service resourcing the only way to provide the appropriate range and number of specialists and specialist teams is in a reasonably large acute general hospital. The tension between access and quality which exists in any health care system is aggravated when that system is seriously under resourced. Innovative suggestions like those of Andy Black do need to be trialed. The evaluation of such trials needs to include not only clinical outcomes and access but also costs and effective use of resources. Doctors working in hospitals expect to base their practice on published evidence from basic and clinical science. We should expect the same of planners. The National Health Service provides a wonderful, and thus far, woefully under utilised test bed for the evaluation of different models of healthcare delivery. Brian Harrison Consultant Physician David Ralphs Consultant Surgeon Norfolk and Norwich University Hospital, Norwich, NR1 3SR brian.harrison@norfolk-norwich.thenhs.com References 1. Smith R. How best to organise acute hospitals services? BMJ 2001; 323: 245-6. 2. The Royal College of Surgeons of England. The provision of elective surgical services. London: RCS; December 2000. 3. Pearson MG, Ryland I, Harrison BDW (on behalf of the BTS Standards of Care Committee). National audit of acute severe asthma in adults admitted to hospital. Quality in Health Care 1995; 4: 24-30. 4. Masson J, Bramley PN, Herd K, McKnight GM et al. Upper gastrointestinal bleeding in an open-access dedicated unit. J R Coll Phys Lond 1996; 30: 436-42. 5. Schreiber TL, Elkhatib A, Grines CL, O’Neill WW. Cardiologists versus internist management of patients with unstable angina: treatment patterns and outcomes. Journal of the American College of Cardiology 1995; 26: 577 -82.