How best to organise acute hospital services?

BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7324.1305 (Published 01 December 2001) Cite this as: BMJ 2001;323:1305

Models of healthcare delivery need to be compared in trials

  1. Brian Harrison (brian.harrison@norfolk-norwich.thenhs.com), consultant physician,
  2. David Ralphs, consultant surgeon
  1. Norfolk and Norwich University Hospital, Norwich NR1 3SR
  2. Royal Victoria Hospital, Belfast BT12 6BA
  3. House of Commons, London SW1A 0AA
  4. Worcestershire Health Authority, Worcester WR4 9RW

    EDITOR—Smith ponders how acute hospital services are best organised.1 Current proposals commend hospitals and networks serving populations of 500 0002; Smith writes that the evidence that hospitals of such size are necessary to ensure high quality care is moderate for some surgical services but unclear for medical services.

    But evidence in the surgical and oncological literature shows that outcomes of malignant diseases are better when patients are looked after by specialist teams rather than generalists. Similar evidence applies to joint replacement, treatment of fractured neck of femur and urological conditions, and vascular surgery.

    Medical emergencies are a large part of care in most acute general hospitals in the United Kingdom. It was to deal with these that Andy Black devised his model (described by Smith), whereby patients would be first admitted to a local small hospital that would, in effect, be an assessment arm of the big hospital.

    Studies in the past 10 years across the range of medical emergencies have shown better care in terms of process and outcome for asthma,3 gastrointestinal haemorrhage,4 ischaemic heart disease,5 stroke, and rehabilitation in acutely ill elderly patients. Delay in implementing optimal management in such conditions can affect outcome.

    As well as achieving better outcomes, specialist teams also achieve more precise diagnosis. In the respiratory field in our hospital, patients with chronic obstructive pulmonary disease or the hyperventilation syndrome are misdiagnosed as having asthma almost …

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