Lack of community care is responsible for crisis in hospitals, meeting hears

BMJ 2013; 346 doi: (Published 20 March 2013) Cite this as: BMJ 2013;346:f1851
  1. Nigel Hawkes
  1. 1London

Hospitals filled with patients who do not need to be there have brought the urgent care system to the verge of failure, a meeting was told on 19 March. “We need change immediately,” said Mark Newbold, chief executive of the Heart of England NHS Foundation Trust in Birmingham. “It’s imperative.”

The problem was not that patients had been admitted inappropriately but that they could not be discharged because they had nowhere to go.

“Twenty years ago there used to be a lot of non-ill patients on the wards,” he said. “That’s no longer true. Our problem is the inability to discharge patients who no longer need acute care, because there is nowhere for them to go. There is not enough support in the post-acute stage.” Hospital beds in his trust were full at the moment, and more than 100 of the beds were occupied by patients who ought to have been discharged, he said.

The meeting, held at the healthcare think tank the King’s Fund, was part of a programme designed by the fund to encourage new thinking about how care should be organised. Moving care closer to home had long been a slogan, but the NHS had struggled with turning it into a reality, said Anna Dixon, director of policy at the fund. Did patients actually want it? They liked convenience, but if the policy meant the closure of local hospitals they quickly turned against it.

The answer, several speakers suggested, was to create a different pattern of care in which the traditional division between generalists and specialists was blurred. “There are not enough generalists in hospitals and not enough specialists in primary care,” said Nigel Edwards, a senior fellow at the fund. Responsiveness to need differed dramatically between different sectors of care, he said: although hospitals worked against the stopwatch, community care worked on the calendar. Community care responded so slowly to the needs of individual patients that there was often no choice but to admit them to hospital—the only part of the system, as Jonathan Fielden of University College Hospital pointed out, that is open 24 hours a day, 365 days a year.

Self management of long term conditions could reduce hospital admissions, argued Renata Drinkwater, chief executive of the Expert Patients Programme. Her claim was supported by Howard Stoate, who chairs the clinical commissioning group in Bexley, southeast London. He said that redesigning care for people with diabetes, including employing a specialist in a role outside hospital, had cut admissions; and the same was true for chronic obstructive pulmonary disease. Martin Marshall of University College London was more pessimistic, arguing that very few interventions had ever been shown to reduce admissions.

What incentives were needed to encourage the development of new patterns of care? There was general agreement that the Payment by Results scheme, by encouraging hospitals to undertake more activity, was a perverse incentive but less agreement that changing it was all that was needed. Cultural change was also needed, several speakers said, along with the abolition of artificial barriers between social care, which was means tested, and healthcare, free at the point of use. A more responsive community care system was another need.

“We need an upscaled pilot of community care that comes into hospitals and pulls the patients out,” suggested Newbold.

The peer Sally Greengross, who chairs the all party parliamentary group on dementia, said that the Scandinavian model of the “hospital-hotel” was worth a serious look. These provide places where people with dementia can live, where their families can visit at all hours, and that are co-located with hospitals so that clinicians are close at hand when needed.


Cite this as: BMJ 2013;346:f1851