Alternatives to hospital for older people must be found, says NHS chief

BMJ 2013; 346 doi: (Published 22 January 2013) Cite this as: BMJ 2013;346:f453
  1. Nigel Hawkes
  1. 1London

Hospitals are “very bad places for old, frail people,” the chief executive of the NHS Commissioning Board, David Nicholson, believes. Hospitals’ focus on getting a diagnosis, referring the patient to the right place, and getting treatment is unsuited to a patient population, 40% of whom will have some form of dementia, he told the Independent newspaper in an interview.1

“We need to find alternatives,” he said. “We need to put as much focus on that as we do on telling nurses to be more compassionate.” Nicholson used the example of people with dementia to emphasise the drive to take “large amounts” of care out of hospitals and into the community. He warned that hospitals would face a double challenge, losing services as a result of concentrating specialist care in fewer centres and of shifting services into the community. “How we manage that is going to be quite tricky,” he admitted.

Responding to Nicholson’s remarks, the Alzheimer’s Society said, “The awful truth is that Sir David is right. People with dementia are going into hospital unnecessarily, staying too long, and coming out worse. Supporting people with dementia in the community will prevent them reaching crisis point and needing costly hospital care. This is not only beneficial for the person but makes financial sense for an NHS stretched to breaking point.

“Reducing the time that people with dementia stay in hospital by just one week could save the NHS millions a year. Supporting the 800 000 people with dementia in the UK to live well in the community needs to be established as a top priority for the new NHS Commissioning Board.”

As the report of the public inquiry into failings at Mid Staffordshire NHS Foundation Trust comes closer, Nicholson is finding plenty to say. Last week he gave an interview to the Health Service Journal in which he asserted the centrality of the NHS Commissioning Board’s role in reconfiguring hospital services. This is likely to grate with the emerging clinical commissioning groups, which also lay claim to a voice in any changes in hospital services. But Nicholson was clear in both interviews. “It’s hard to imagine a service change that’s going to take place over the next few years, which the commissioning board is not directly involved in,” he told the Health Service Journal.2 “We’re not this kind of supervisory body sat over here. We’re going to be much more engaged and involved and much less slightly standing back watching what’s happening.”

He asserted that the shift of power to the board and away from ministers would make the process of change very different. “What used to happen was that because politicians were very powerful, [NHS managers] thought that the way you got things done was to get the politicians to say it needs to be done and then tell everybody to do it,” he said in his Independent interview.1 “But of course change doesn’t happen like that. All you get is a system which is constantly trying to read the runes of what the politicians want. That is a very difficult place to be . . . This shift [to the board] will allow people to take more control over their own affairs but also feel much more accountable to their patients.”

The board has already announced a nationwide review of emergency services,3 which is likely to provoke strong opposition should it recommend, as seems inevitable, the closure or downgrading of some hospital emergency departments. But Nicholson showed no hesitation in backing the reconfiguration of services to improve outcomes.

“We’ve done quite a lot but need to do much more,” he told the Independent.1 “If you’re asking me. ‘Do I want to be operated on for my oesophageal cancer with a general surgeon [locally] or by someone who does nothing other than oesophageal surgery?’ I’ll go for the specialist every time.”

Nicolson seems confident that his own position is secure, whatever general criticisms the public inquiry report may make of NHS management. This is despite the fact that he was chief executive of Shropshire and Staffordshire Strategic Health Authority during 2005 and 2006, part of the period covered by the inquiry. He claimed in evidence to the inquiry that Mid Staffordshire’s failings were not indicative of a “systemic” issue and told the Health Service Journal that “nothing I’ve seen” would indicate that he was under threat.4 Like other key witnesses who could face criticism, Nicholson may have had a letter from the inquiry’s chairman, Robert Francis QC, warning him that he may be criticised. But he said that he had been required to sign an undertaking not to discuss any letters that “he may or may not” have received.


Cite this as: BMJ 2013;346:f453