Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Getting real about care closer to home

BMJ 2017; 356 doi: (Published 23 March 2017) Cite this as: BMJ 2017;356:j1428
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

There’s a growing consensus about how we must change to ensure sustainable future health services. Its essence is: let’s focus more on public health, prevention, and wellbeing; enhance primary and wider community support for people with long term conditions; and, during acute crises, help patients spend less time in hospitals—or none at all—repurposing resources and staff away from hospital buildings.

In England we see such ambitions and rhetoric in political pronouncements and in key documents such as the NHS Five Year Forward View,1 sustainability and transformation plans (STPs),2 and position papers from professional organisations.34

These grand ideas aren’t new, but they remain unmatched by grand actions. This isn’t surprising, when service leaders must balance imagined future benefits against tangible current pressures in broke, full acute hospitals—admitting that they can no longer hit high profile and politically sensitive performance targets.5

These grand ideas aren’t new, but they remain unmatched by grand actions

The health announcements in the chancellor’s March 2017 spring budget further exposed this dissonance.6 First, Philip Hammond promised an extra £100m for GPs based in emergency department triage—even though upstream conventional primary care, with the potential to help keep patients away from them, is experiencing workforce and workload crises and has 100 fewer GPs this year despite plans to recruit 5000 more.7

Social care was promised a further £2bn uplift over the next three years. But this announcement was clearly labelled in terms of reducing delayed transfers from—you guessed it—acute hospitals.8 Senior NHS leaders encouraged these hospitals to “get lippy” about use of the social care money.9 Little mention, then, of supporting people and their carers to stay at home in the first place, although this is at the core of social care’s purpose.

Hammond promised an additional £325m of capital expenditure for “leading” STPs (again, more on buildings rather than on staff and services in people’s own homes).10 Some £800m in funds held by clinical commissioning groups and earmarked for primary and mental health was then repurposed by NHS England to meet hospital deficits and pressures.11

Opinion polls show that responsive, urgent care tops public concerns about the NHS.12 Politicians and journalists reinforce this by discussing it predominantly in terms of hospitals and beds. This high visibility and the narrow focus on acute care performance become a distorting, overvalued idea.

If we’re serious about a shift towards the preventive and coordinated care we claim to want, we can’t keep pumping all additional new funds into supporting hospitals. We’ll need to relax our expectations of hospital performance and be honest about what they can no longer offer, let alone improve.

Maybe in the autumn statement we’ll put our money where our mouth is. Platitudes don’t help patients.



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