Intended for healthcare professionals

Rapid response to:


One in four hospital patients should be cared for out of hospital

BMJ 2011; 343 doi: (Published 29 December 2011) Cite this as: BMJ 2011;343:d8336

Rapid Response:

Re: One in four hospital patients should be cared for out of hospital

I am glad to see this topic covered in the News Section of this week's Journal (BMJ 2011;343:D8336.)

This subject was also covered on the main news at 8am 29th December on the Today programme Radio 4. The first item was a statement from the NHS Confederation that 1 in 4 hospital patients would be better off being looked after in the community. This was followed at 8.10am by an interview with the Chief Executive of the NHS Confederation Michael Farrar.

He repeated this controversial statement to the interviewer James Naughtie. I waited for the fundamnetally important next question: Where is the evidence? To my amazement the question was never asked. Instead the statement was accepted as a fact not to be challenged. I also waited to learn if other individuals somewhat better informed with facts than Mr. Farrar were to give their opinions. Indeed a statement without evidence is no more than an opinion. If we are to have opinions then at least they should be grounded on a foundation of evidence and personal experience. Perhaps somebody from the Royal College of Physicians and/or the Royal College of General Practitioners were to be invited to contribute. Sadly this was not the case.

Mr. Farrar was treated as the only source of information and an expert on the subject, a very exalted position for a mere health service manager. I suspect he was espousing the current dogma from the Department of Health who are cutting funding so severely that Primary Care is to be kept afloat by cutting Secondary Care along classical Thatcherite lines. He did not bother to enlighten us on the nature of the 25% of patients apparently blocking hospital beds. From my experience they are likely to be the frail elderly with multiple pathology previously living in social isolation, and most likely deprived communities with meagre financial resources. Successive governments have been aware of this issue for the forty years I have been involved with the NHS and they have done spectacularly little about it. In fact the situation is set to become worse.

In case Mr. Farrar has not noticed residential care homes have been closing down, and more may well follow. Only in September this year the future of 750 care homes run by Southern Cross was hanging in the balance because of funding problems caused when private equity meets public service. The government was not prepared to step in and prevent this business closing down with disastrous effects on the residents. The origin of the problem with Southern Cross stemmed from legislation in the Thatcher years intended to bring the efficiencies of private enterprise into social care!! An early example of the Big Society in action perhaps?

Frail elderly people with multiple health problems living with carers need a lot of care, medical, nursing, paramedical and social. Living alone they need even more. Unfortunately central government continues to make things worse rather than better. It is no longer possible for a patient's own GP to organise and take responsibility for an out of hours service. The GPs voted to divest themselves of this responsibility which now means we have second or third rate out of hours cover.

Community Nursing posts have been drastically cut down as a result of the financial savings demanded by government. The funding for Community Nursing and Healthcare Assistants across 45 Primary Care Organisations in the UK was £9 million in 2010/11 and is due to fall to £8.5 million in 2011/12 with the number of frail elderly growing. How will this improve care in the community? No when this government and its acolytes at the NHS Confederation talk about care in the community they really mean care in your own home out of sight. Out of sight so that nobody can see not just bad care but non-existent care. Indeed an NHS in which Primary Care is dominant with the burden of care imposed on the community is in fact the care advocated for third world countries with third world budgets. Just how low has the UK sunk under our incompetent politicians with their vested interests?

The politicians have grasped that people are living longer, but nobody has appreciated except doctors and nurses that many of these elderly people are not fit and healthy, they are frail with thin fragile bones, weak muscles, worn out joints, shrunken brains, failing hearts to mention a few of the problems. If we are to look after them properly they need good Primary Care and good Secondary Care. In this situation you cannot fund Primary Care by cutting down on Secondary Care. This is what Mr. Farrar is really saying and I am sure the government is pleased he is saying it. Interestingly he went on to talk about better outcomes if some patients travel further for treatment, to centres of expertise I presume. This would enable the closure of some hospitals which we should all support apparently. Certainly patients need treatments that offer the best outcomes, I presume Mr Farrar is referring to Primary Coronary Angioplasty, Neurosurgery, Vascular Surgery and Major Trauma? However this still leaves an awful lot of medical problems that can be managed at the local hospital.

If politicians and managers really listened to what the people want instead of insisting they want more choice and care in their own homes, they would discover the man in the street is very pragmatic and practical. He wants decent local medical services both Primary and Secondary. Those families with children and the elderly would like their own GP to oversee their care. They want good Community Services with enough Community Nurses to look after them at home when home circumstances are appropriate. When they have a significant health problem acute or chronic they want to go to a clean, well-run, competent and caring local hospital that can look after the needs of the common ailments that afflict mankind. Is this too much to expect in a first world country in the 21st century? Most of them accept that very clever things may require them to travel, but this should be the exception rather than the rule.

Mr Farrar and the government are laying down a smoke screen of propaganda for 2012, the year of more Draconian cuts to the nation's most precious asset, the NHS. Let us not be fooled.

Competing interests: No competing interests

08 January 2012
Kenneth G Taylor MD.,FRCP
Consultant Physician