Not So Acute

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

In this week’s blog, Professor David Hands explores the relationship between the language we use and the strategic tasks we face in healthcare.  He points out that the conflation of ‘acute’ with ‘hospital’ is fundamentally misleading, and distorts our thinking.  David is a Visiting Professor at WIHSC and has held a variety of chief executive roles in the NHS in England and Wales over many years.

Not So Acute

When the words and phrases we use to communicate ideas become obsolete, they must be abandoned. My favourite for retirement is ʻacute servicesʼ. We need more subtle and accurate concepts to guide NHS development.

The sloppy thinking encompassed by this phrase helps to perpetuate the myth that general hospitals are the only places where serious illness is managed and are therefore the most important component of the healthcare system. Other elements are diminished.

The description bears little relationship to any clinical assessment of the relative severity of illness. For example, a patient with a long-standing skin condition referred to a dermatologist is classified administratively as ʻacuteʼ whilst another, experiencing a severe psychotic episode, is not. Organisational descriptions should be more in tune with clinical reality and patient need.

The term is derived from the early hospital statistical returns when many patients, particularly the elderly, mentally ill, infectious and disabled, were warehoused in long-stay hospitals, classified as “non-acute”. The distinction is now as defunct as those hospitals.

Out-moded concepts impede multidisciplinary understanding of the organisational arrangements required to improve outcomes and cost-effectiveness. There are more useful models. For example, the WHO distinction between primary (or generalist) and specialist (secondary or tertiary) services is much more valuable.

According to the WHO definition, primary care includes both prevention of illness and the point of first contact with health services. Primary care is also critical to the holistic management of co-morbidity and chronic conditions and follow through from specialist treatment.

The relationship between primary care and specialist services is much more complex than the simple notion of “referral”. For example, specialist doctors became known as ʻconsultantsʼ because of their role in providing advice and support as well as accepting transfers of care.

The concept of primary care is also much wider than GPs. It includes a wide range of community-based professionals including pharmacists, dentists, optometrists, podiatrists, therapists, nurses and those in public health. Conceptually, as the point of first contact, it should also include paramedics and hospital-based accident and emergency services. The concept of primary care is understood in this broader way, the potential for strengthening its contribution and its relationship with specialist services becomes clearer.

Similarly, the concept of specialist services stretches well beyond the confines of institutions. Psychiatry, paediatrics and geriatric medicine are generally recognised as requiring a strong community base or orientation. Most medical (as opposed to surgical) specialties also have a significant preventative component. Surgical specialties require specialist facilities but, now that almost 70% of surgery is possible on a day-case basis, traditional hospital beds are not critical. When patients go home quicker, the contribution of GPs and community staff is.

The distinction between primary and secondary services is helpful but the boundary between them requires tailored refinement and re-definition. Changing patient needs and medical technology require the explicit development of a range of collaborative, vertically integrated, health systems to respond to different types and levels of need. The roles and responsibilities of every component of each system, in relation to the overall goal of improving both individual and community health, needs careful re-definition.

The focus needs to shift to the evidence-based ways in which each specialist service can be re-orientated to better support re-organised primary care, including changes in location where appropriate. Similarly, the responsibilities and organisation of primary care in relation to specialist services needs to be spelt out.

Much work has already been done to define protocols and pathways but these tend to be limited to prescriptive guidance on patient referrals and relatively linear treatment processes. A more fundamental multi-disciplinary renegotiation of roles, relationships and responsibilities, referenced to a hierarchy of health outcomes, is required. This requires significant effort and sustained development support.

The adoption of more relevant concepts can assist development of better structures, systems and processes. However, there are other obstacles and disincentives. The internal market promoted fragmentation and perverse incentives to increase inappropriate specialist referrals and hospital admissions. It must be abandoned. Similarly, payment systems which reward activity at the expense of quality and outcomes will need to be replaced by outcome-orientated performance management supported by programme budgets.

Having already ditched the market in favour of more appropriate population-based health authorities, Scotland and Wales are in an ideal position to move quickly towards integrated health networks. England has more (dis)organisational baggage but the recent advent of ʻvanguardsʼ and ʻnascent health systemsʼ offer the possibility of change. When there is a widespread consensus that an in-patient hospital admission indicates system failure, we will know we have achieved success.

By David Hands

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