Views And Reviews Acute Perspective

David Oliver: Hospitals are not the enemy

BMJ 2016; 355 doi: (Published 06 October 2016) Cite this as: BMJ 2016;355:i5312
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

Even as an acute hospital doctor I recently shouted at the television, when Newsnight reduced a debate on the whole NHS to one about hospitals,1 “There are other services, you know!” I understand why non-hospital staff are even more exasperated at the obsession with hospitals.

The health service’s internal commentariat repeatedly blames hospitals, and the frontline staff who work in them, for the NHS’s problems.2 3 4 We’re too financially dominant, apparently, and the government gives us too much priority. It argues that hospitals, in their current form, inhibit vital investment in primary and community services and prevention.

I’m fed up with this simplistic narrative. Like anyone else, we’re just trying to get on with treating the patients who arrive.

Under several recent governments the NHS has indefensibly, chronically failed to invest in primary and community services despite rising demand.5 6 7 Too great a proportion from funding increases has gone to acute hospitals and too little to services to support people outside them.

And we still have too many acute beds occupied by people whose needs could be met elsewhere, as recent figures on delayed transfers of care show.8 9 That said, England has fewer hospital beds per capita than most countries, and hospitals are nearly full all year round, impairing performance.10 11

But many things are simply outside hospitals’ direct control.

Unscheduled admissions are rising, with many admitted patients bypassing primary care referral altogether.12 Yet we can control neither acute demand nor ambulance response targets, nor the public seeking help who prefer to visit emergency departments,13 nor a national four hour target in emergency departments that drives doctors to use adjacent acute medical units for assessment and stabilisation. This is often the right thing for patients: better than a spell in an overcrowded emergency department, a rushed discharge, or a preventable admission.

The notion that NHS hospital clinicians are driven by financial considerations to admit more patients is insulting.14 Few are thinking about payment mechanisms while desperately trying to get people back home and to find beds.

We don’t control delays in patients accessing step-down community services that don’t work at the pace that post-acute hospital patients require, and these delays are worsening.8 15

Waiting time targets are skewed towards hospital activity. Having to prop up acute hospitals in deficit makes essential investment in community services harder. But many populations have only one district general. Simply closing beds will make a bad situation worse. Transitional funding, as proposed by the King’s Fund’s Barker commission, could create extra capacity in the community, and we should allow these alternative services to mature first.16

In a system where collaboration counts, let’s stop using hospitals as a convenient scapegoat for much broader problems.

The notion that hospital clinicians are driven by financial considerations to admit more patients is insulting



View Abstract