Community hospitals, or centralised hospitals? We need both

Something was lost in translation yesterday in the reports that the new chief executive of the NHS, Simon Stevens, was calling for smaller community hospitals to play a bigger role in the care of the elderly. Headlines proclaiming that the former adviser to Tony Blair was signalling a return to 1950s-style cottage hospitals and that his remarks represented an abrupt change in policy away from the big centralised hospitals that have been favoured up to now prompted immediate denials from NHS England.

It appears that Mr Stevens did not choose his words carefully enough. What he meant was that while some services would still be concentrated in specialist centres, it was also clear that “smaller hospitals can play an important role”. But it is not a case of either/or – we need both.

Centralisation is vital for certain specialities to guarantee a minimum throughput of patients necessary to maintain specialist skills and drive up standards. In the case of stroke services, for example – provided in 30 hospitals across London until 2010 which were then centralised in eight bigger trauma centres – the move was credited with saving 400 lives by 2013. There will be no turning back.

But not all hospital patients require specialist services. Two-thirds are over retirement age, many with multiple long-term problems. The number of people admitted for less than two days since 2000 has more than doubled – an indication we are “not getting it right”, Mr Stevens said. These patients need something different from the highly specialised, technically sophisticated treatment required for stroke victims. They need careful monitoring by vigilant staff who can spot when things are going wrong – blood sugar rising, oxygen levels falling – and intervene before a problem develops into a crisis.

This is care that largely should be delivered at home and might be co-ordinated by a local hospital in a seamless service from bedside to hearthside. It is in “thinking creatively how to achieve this” that smaller hospitals may find a new role, said Mr Stevens. What he did not acknowledge is that the thinking has gone on for 20 years. It is action we need now.