Farewell to the dear old district general hospitals

THE DOCTORS have a plan. It is a grand plan and it calls for a bold political initiative. They want to close or downgrade the local hospitals, many housed in outdated buildings, that litter the country and replace them with fewer, larger palaces of disease which are able to provide the advanced medical care that patients will expect in the 21st century.

But there is a problem. It can be summed up as the mums-with-prams syndrome. No local community welcomes the closure of a local hospital, as MPs, NHS managers and doctors have learnt to their cost. Mums-with-prams make vocal and photogenic demonstrators quite capable of derailing the best laid plans. Politicians confront them at their peril.

This is how the battle lines are drawn. As the latest report calling for widespread hospital closures, from the Royal Medical Colleges, lands on health secretary Frank Dobson's desk, it is worth asking what sort of health service we want?

The argument can be summed up in a phrase: access versus quality.

Which is more important to the patients of tomorrow: to be able to hop on a Number 9 bus and get to hospital in 20 minutes where basic care will be good but you will take pot luck if you are in need of specialist attention? Or to face a journey of 40 to 50 miles with the promise that when you get to hospital the care you will receive will be the best the NHS can offer?

Most people naturally reject these alternatives demanding the best care on their doorstep, but the gloom-mongers of the Royal Medical Colleges say it simply isn't possible. Under their chairman, Charles Collins, a consultant surgeon in Taunton, Somerset, their report says: "It is important for the public to recognise that it is not possible for each locality to have its own small hospital to provide anything other than a restricted service. This may well not include an accident and emergency unit or acute medical and surgical services."

There are good reasons why this is the case. Medical care has advanced to the point where no single specialist has the knowledge and expertise to provide top quality care. Medicine is now a team activity in which groups of specialists combine their expertise to tackle disease and secure the best outcomes for patients. In a report a year ago, the British Medical Association, the Royal College of Physicians and the Royal College of Surgeons said there should be no single-handed consultants in any of the main medical or surgical specialties, regardless of the size of hospital. The growing complexity of medicine meant specialist treatment could no longer be provided without the back-up of a full medical team.

A consequence of this increased complexity is a shortage of patients. There are not enough doctors to staff specialist teams to the requisite standard in every hospital because there are not enough patients requiring specialist care to sustain the expert teams to care for them. Doctors in training require raw material - patients - on which to hone their skills but these can only be provided in sufficient numbers in centres serving large populations. Last year's joint report by the BMA and the colleges of physicians and surgeons called for "super hospitals" serving populations of 500,000, about twice the size currently served by the average district general hospital, to overcome the problem

The current Royal Medical Colleges' report has grown out of the earlier one as the surgeons and physicians recognised that they would strengthen their case if they can get their colleagues in the other colleges (gynaecology, paediatrics and so on) to join the cause.

Their vision does not require the outright closure of large numbers of hospitals but they argue many might be downgraded to provide low-tech care in co-operation with nearby specialist centres.

There is nothing new in this suggestion. Similar recommendations have been made in a clutch of reports over the years. What patient would willingly undergo an emergency operation in the dead of night by an unsupervised junior doctor? The regular surveys by the confidential enquiry into perioperative deaths (within 30 days of surgery) in 1997 identified operations by unsupervised juniors - accounting for one fifth of all those performed out of hours - as those carrying the greatest risks. The response of the Royal College of Surgeons was to call for emergency work to be concentrated in half the present number of hospitals, leaving the remainder doing routine work.

On the same grounds the Audit Commission in 1996 suggested the closure or merger of more than a quarter of accident and emergency departments because they were seeing too few patients - less than 50,000 - to support a full range of specialist services. Intensive care beds are being grouped in fewer centres to concentrate expertise - which means we can expect more helicopter dashes with mortally ill patients in search of expert care.

The argument behind this drive to centralise is that doctors and hospitals treating larger numbers of patients provide better care. But it is not accepted by all. Critics argue that the strategy is flawed as it still remains to be proved that bigger necessarily means better. A study by the Centre for Health Economics at the University of York found "no good evidence" that increasing the size of hospitals improved outcomes.

Answering these intellectual challenges (what patient would reject the offer of expert care for lack of evidence that it was superior?) may be less difficult than the political objections. Change is hampered by the fear, shared by all MPs, of demonstrators (mums-with-prams) turning out in their constituencies, waving placards and rattling tins. Yet the fierce dependence on the local hospital may be about to change.

New styles of care mean increasingly that the "hospital" is moving out into the community. Consultants are holding clinics and performing tests in GPs' surgeries, and patients are having remote consultations with consultants in hospital using advanced video technology. New walk-in clinics announced by Mr Dobson in June, which are being piloted in 20 places around the country, may ease the pressure on, and the demand for, accident and emergency units.

The future of the NHS clearly lies, at one end, with palaces of disease providing the full panoply of specialist care and, at the other, with local clinics and day surgery units offering easy access to routine care. But the days of the district general hospital, promising more than it can deliver, are numbered.