Views & Reviews Personal View

There’s no evidence that 25% of hospital patients would be better off cared for out of hospital

BMJ 2012; 344 doi: (Published 25 January 2012) Cite this as: BMJ 2012;344:e587
  1. Kenneth G Taylor, consultant physician
  1. 1Birmingham
  1. kandgtaylor{at}

The NHS Confederation recently said that one in four hospital patients would be better off being looked after in the community (BMJ 2011;343:d8336). The subject was covered on Radio 4’s Today programme and was followed by an interview with Michael Farrar, chief executive of the confederation.

He repeated this controversial statement to the interviewer and I waited for the fundamentally important next question: “Where is the evidence?” But the question was never asked. Instead the statement was accepted as fact. I also waited to learn whether people better informed than Mr Farrar were to give their opinions. A statement without evidence is no more than an opinion, and if we are to have opinions then they should be grounded on a foundation of evidence or personal experience. Perhaps somebody from the Royal College of Physicians or the Royal College of General Practitioners would be invited to contribute? Sadly this was not the case.

Mr Farrar was treated as the only source of information and an expert on the subject—an exalted position for a health service manager. I suspect he was espousing current thinking from the Department of Health, which is cutting funding so severely that primary care is to be kept afloat by cutting secondary care, along classic Thatcherite lines. He did enlighten us about the nature of the 25% of patients who are apparently blocking hospital beds. From my experience they are likely to be frail elderly people with multiple pathology, previously living in social isolation, most likely in deprived communities, and with meagre financial resources. Successive governments have been aware of this problem for the 40 years that I have been involved with the NHS, and they have done spectacularly little about it. In fact the situation is set to become worse.

Mr Farrar may not have noticed that residential care homes have been closing down, and more may well follow. In 2011 the future of 750 care homes run by Southern Cross hung in the balance because of funding problems caused when private equity meets public service (BMJ 2011;343:d7964). The problem with Southern Cross stemmed from legislation brought in during the Thatcher years that was intended to bring the efficiencies of private enterprise into social care.

Frail elderly people with multiple health problems living with carers need a lot of care—medical, nursing, paramedical, and social. Living alone they need even more. Unfortunately central government continues to make things worse rather than better. It is no longer possible for a patient’s own general practitioner to organise and take responsibility for an out of hours service. General practitioners voted to divest themselves of this responsibility which now means we have second or third rate out of hours cover.

Community nursing posts have been drastically cut as a result of the financial savings demanded by government. The funding for community nursing and healthcare assistants across 45 primary care organisations in the UK was £9 million in 2010/11 and is due to fall to £8.5 million in 2011/12 while the number of frail elderly grows. How will this improve care in the community? When this government and its acolytes at the NHS Confederation talk about care in the community they really mean care in your own home, out of sight. Out of sight so that nobody can see—not just bad care, but non-existent care. A national health service in which primary care is dominated by the burden of care imposed on the community is in fact the care advocated for third world countries with third world budgets. Just how low has the UK sunk under our incompetent politicians with their vested interests?

Politicians have grasped that people are living longer—they do not seem to appreciate that many of these elderly people are not fit and healthy. Often the elderly are frail with thin fragile bones, weak muscles, worn out joints, shrunken brains, and failing hearts. If we are to look after them properly they need good primary care, and good secondary care. In this situation you cannot fund primary care by cutting the funding of secondary care. This is what Mr Farrar is really saying and I am sure the government is pleased he is saying it. When interviewed he went on to talk about better outcomes if some patients travel further for treatment—to centres of expertise, I presume. This would enable the closure of some hospitals, something which apparently we should all support. Certainly patients need treatments that offer the best outcomes, and I presume Mr Farrar was referring to primary coronary angioplasty, neurosurgery, vascular surgery, and major trauma. This still leaves an awful lot of medical problems that must be managed at the local hospital.

People are generally pragmatic and practical. We want decent local medical services, both primary and secondary. Most people, including the elderly, would like their own general practitioner to oversee their care. They want good community services with enough community nurses to look after them at home when circumstances are appropriate. When they have a substantial health problem, acute or chronic, they want to go to a clean, well-run, competent, and caring local hospital for treatment. Is this too much to expect in a first world country in the 21st century? Most people accept that some circumstances may require them to travel, but this should be the exception rather than the rule.

Mr Farrar and the government are laying down a smoke screen of propaganda for 2012, the year of more Draconian cuts to the nation’s most precious asset—the NHS


Cite this as: BMJ 2012;344:e587


  • Competing interests: None declared.

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