Education And Debate The hospital of the future

Better out than in? Alternatives to acute hospital care

BMJ 1999; 319 doi: http://dx.doi.org/10.1136/bmj.319.7217.1127 (Published 23 October 1999) Cite this as: BMJ 1999;319:1127
  1. Martin Hensher, health economist, London Health Economics Consortium (henshm@hltrsa2.pwv.gov.za)a,
  2. Naomi Fulop, senior lecturer in health services management and policy, Health Services Research Unita,
  3. Joanna Coast, lecturer in health economicsb,
  4. Emma Jefferys, health economist, London Health Economics Consortiuma
  1. a London School of Hygiene and Tropical Medicine, London WC1E 7HT
  2. b Department of Social Medicine, University of Bristol, Bristol BS8 2PR
  1. Correspondence to: M Hensher

    This is the fourth in a series of seven articles.

    Changing technology is probably the main force driving the substitution of healthcare resources. This is because new treatments, procedures, and diagnostic techniques allow conditions to be managed in different settings by different staff. Such change is generally incremental, but occasionally new technologies fundamentally change the organisation of care. For example, the development of effective chemotherapy in the 1940s allowed tuberculosis to be managed on an outpatient basis, which led directly to the closure of nearly 30 000 hospital beds and the elimination of an entire class of hospital. Advances in primary prevention might also, in the long term, lead to a reduced need for admission to hospital. Yet such step changes are ultimately outside the hands of clinicians, managers, and policymakers, despite their intimate concern with the organisation, scale, and cost of the hospital sector. The policy debate has tended to focus on what might be described as the “appropriateness gap”—how to provide substitute care for inpatients who do not strictly need to be in hospital because of current technologies.

    Summary points

    Changes in diagnostic and treatment technologies, rather than policy interventions, are the most potent force leading to the substitution of one form of healthcare service for another.

    Many inpatient bed days and admissions are deemed inappropriate—but the appropriateness of admission to hospital can tell us nothing about whether patients would be more cost effectively cared for outside hospital.

    Several services that attempt to be substitutes for hospital care—either by preventing admission or by hastening discharge—have been experimented with.

    Many apparent substitutes for hospital care seem, in the United Kingdom, to increase overall demand for services, with little impact on overall hospitalisation or costs.

    Inappropriate location of care

    Most patients admitted to hospital in the United Kingdom have no alternative but to be admitted: they …

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