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EDUCATION AND DEBATE: Chris Ham Does the district general hospital have a future? BMJ 2005; 331: 1331-1333 [Full text]

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What about truly rural hospitals?

Peter J Milewski   (6 December 2005)

'competition'

benjamin dean   (6 December 2005)

The DGH is one of the jewels in the NHS crown.

S. Michael Crawford   (11 December 2005)

District General Hospitals - Future Tense

Prasenjit Raychaudhuri   (15 December 2005)

What about truly rural hospitals? 6 December 2005
Peter J Milewski, Consultant in General Surgery Withybush Hospital, Haverfordwest, Pembrokeshire, SA61 2PZ Send response to journal: Re: What about truly rural hospitals?	Professor Chris Ham clearly has the governments of both England and Wales in tow regarding his ideas on market reform in the NHS. Certainly it is sensible to rationalize services that may be duplicated in several hospitals all within a radius of ten to fifteen miles, as may be found in many cities or other densely populated areas. However, having recently attended a seminar of his, I have been unable to discern any attempt by Professor Ham to justify his ideas in a truly rural context. Nothing of his answers the query ‘How do you maintain the skill mix to deal with acute life-threatening conditions in a hospital that is thirty miles from the next DGH up the road?’. The answer, of course, is that you have to maintain it as a DGH in its own right. To do that you cannot chip away at some services and hope that the others will be maintained. For example, if you acknowledge that you need somebody around with the skills to deal with a ruptured spleen or a massive haematemesis, then you have to accept that you won’t get such a person if you expect him the rest of the time to deal only with lumps and bumps. We know this well in Pembrokeshire, as there is historical precedent for it, a patient having died in 1970 as a direct result of the then Welsh Hospital Board’s policies. Small wonder, then, that Dr Brian Gibbons, Minister of Health in Wales, was recently asked at the Welsh Assembly if he would accept a charge of corporate manslaughter if a death occurred in transit as a result of his reforms. Competing interests: Consultant in a truly rural hospital
'competition' 6 December 2005
benjamin dean, sho australia Send response to journal: Re: 'competition'	Yet again competition is being talked of as regards the NHS. State controlled competition is not true 'competition' as the decisions made by the state are all important, and end up undermining any competition present. If true competition were present the freedom of consumer choice would be all important. As it stands any choice will only be of the 'pseudo' variety. Different providers whether public or private work to meet the demands set by the state, as regards targets and set payments. These providers only react to state demand, not consumer demand. The state then employs many inefficient ways of measuring consumer demand, in order to set its payment levels and targets. Thus when 10,000 cataract operations are sold in bulk to a private provider, patients are then given a choice of waiting on the NHS or going private for immediate surgery- the choice by the government was all important, not that of the patient. This is pseudo-choice and pseudo-competition. When smaller hospitals, that are struggling for cash due to the way the government has inadequately funded them, have to compete against well funded Foundation hospitals- it will no surprise to see the small ones go under. This will not be due to genuine competition, it will be due to the way the state has funded different hospitals favouring the larger. The state makes all the important choices and their demand is met, unfortunately the patient's is not. This is the problem with pseudo-competition and an example of the paradox of choice in a collectivist system. Yours, Benjamin Dean. Competing interests: None declared
The DGH is one of the jewels in the NHS crown. 11 December 2005
S. Michael Crawford, Consultant Medical Oncologist Airedale General Hospital, BD20 6TD Send response to journal: Re: The DGH is one of the jewels in the NHS crown.	Given that the United Kingdom, through the National Health Service (NHS), spends a smaller proportion of its post domestic product on publicly funded health care than is spent by comparable economies and given that the take up of state funded health care is greater than in the UK than elsewhere, it has to be asked how so small an NHS manages to achieve as much as it does? Although the UK has relatively few doctors and nurses the NHS has two major strengths compared with other systems which. Firstly patients do not have direct access to specialists; this is covered by the gate keeper role of primary care which also is able itself to provide a high proportion of the health care actually needed. The second advantage that the NHS possesses is the District General Hospital (DGH). Enoch Powell’s vision, cited by Professor Ham, of a DGH, the population of something over 100,000 contrasts sharply with hospital provision elsewhere where average population served is around the 50,000 mark. In practice, in the UK a DGH serving fewer than 200,000 people is regarded as small. An institution of 200 to 600 beds is around the optimum for economies of scale [1]. This fact alone should make politicians who are keen to maximise the value for money obtained for the tax payer in health care wish to develop the DGH in preference to small treatment centres on the one hand and large centralised institutions on the other. A further advantage is the multidisciplinary nature of the DGH. Ham rightly points out that the treatment centres must focus on straightforward cases, but this straightforwardness is ultimately a retrospective conclusion and the diversity of disciplines in the DGH are essential when managing issues of any complexity. The enthusiasm for the independent sector treatment centres is a progression from the thinking surrounding the introduction of the internal market in the 1990s. It was always easier for the business advisors to think of trading defined products, so elective surgery which is the aspect of secondary care most readily understood in this way, was the centre of all the discussions. Elective operations, along with imaging investigations, are therefore easy to be considered as products to be purchased from an external provider. Simple uncomplicated surgery is an important but a very small part of the total NHS and this over simplified the business model should not be allowed to control NHS planning. The problem with outsourcing imaging investigations is even greater. Tests themselves do not enhance the health of patients, it is the treatment decision that is instructed by them that is important. The investigation conducted and reported by a radiologist who is part of the DGH multidisciplinary team, is a vastly superior product to the outsourced investigation where a reporting radiologist cannot interact with colleagues. The gatekeeping role of the primary care doctor is valuable in controlling costs but that has its dangers. Its association with the parsimonious culture of the NHS can result in delayed diagnosis and treatment of serious pathology such as cancer and may go a long way to explain the poor performance of the NHS when measured by five year survival of cancer patients [2]. The health care system of the UK must be funded to provide sufficient capacity to meet the demands that are put on it without relying on over-assiduous gatekeeping. A close partnership between primary, secondary and tertiary care teams to provide a timely and appropriate service forms the most cost effective model of publicly funded health care. What was missing in the 1980s was the funding. 1. Hospital volume and health care outcomes, costs and patient access. Effective Health Care, University of York, 2 (8) 1996 2. Crawford SM. Cancer in the UK- A question of culture. Eur J Cancer, 36: 1909-12; 2000. Competing interests: I am a consultant in tertiary specialty in a DGH serving a population of 205,000
District General Hospitals - Future Tense 15 December 2005
Prasenjit Raychaudhuri, clinical fellow in surgery Kings Mill Hospital,Mansfield,ng19 6qx Send response to journal: Re: District General Hospitals - Future Tense	DISTRICT GENERAL HOSPITALS- FUTURE TENSE The District General Hospitals (DGH’s) have been the backbone of the NHS, treating large volume of patients with wide range of ailments at a high level of efficiency and have been important centres of training for junior doctors.However with rapid changes at multiple levels of the NHS and unfolding independent sector participation ,a wide range of issues are at stake .Having worked in both sectors in India where private and public sectors run side by side ,I have a fair idea about the problems that arise.Although the situation in a developing country cannot be strictly comparable to that of a first world country, certain issues like competition ,corporate culture,marketing , public perception and their impact on the health sector are fundamentally similar,though different in time, place and scale. Even before the full range of changes have evolved ,30% of people surveyed in a Market &Opinion Research International (MORI) survey conducted for Birmingham &Black Country Strategic Health Authority(1), show preference for treatment at private hospitals.The continious bad press and public perception of inefficiency ,inspite of high quality of services offered, have unfortunately left the NHS in general and DGH’s in particular ,handicapped to face the competition from the private sector even before the game has begun.Later on,when the full force of corporate financial power and marketing strategy come into play , the NHS, traditionally not geared up for selling itself, may find itself in a difficult situation.The larger university hospitals with their greater infrastructure , funding, educational activities ,and more advanced clinical and therapeutic services will be able to stand up to the competition,but the DGH may find itself at a disadvantage on all these counts. Although an even field is being created at the start by fixing prices with a common national tariff system ,it will not be long before the market forces push prices into an upward spiral.It stands to reason that ,quality,which will be one of the cornerstones of competition, will dictate its own price. As competition escalates into a struggle for market space and fiscal balance becomes the mantra for survival –increasing number of finance management experts will be required, bringing further changes in management styles based on profitability. The necessity of “cost cutting “ to balance finances imply inevitable staff redundancy and restructuring of services.Further on , should “spare hospital capacity” become a reality ,a large number of staff may become redundant.Besides, at some future point ,the lure of better working conditions and financial packages, may paradoxically ,lead to large number of staff at various levels moving on to the private sector -stripping the NHS of valuable human resources and technical expertise. Restructuring of services at DGH levels,if implemented, may well reduce many essential services which become financially unviable and the hospitals left with a narrower spectrum of services as well as patients . The impact on training may be wide ranging .Lesser variety and number of patients may reduce training experience and in the event of some routine surgeries becoming “low priority”(2) and operating lists moving on to the private sector ,opportunities for surgical training will be further restricted. However ,I am sure that these factors have been taken into consideration by those in the driving seat of refoms and appropriate steps have been taken to counter the impact of these possibilities.It will be very unfortunate if these hospitals become the sacrificial lambs on the altar of reforms. References: Ham C.Does the district general hospital have a future?BMJ2005;331:1331- 3(3 December.) Lieske B.Dilemma of a surgical trainee.BMJ2005;331:1347(3 December.) Competing interests: None declared