Monday, 15 December 2014

The Hospital of the Future: New Report (UK)

Sir Michael Rawlins, Chairman of the National Institute for Health and Care Excellence (NICE) since its inception in 1999 until last year, is now Chairman of a committee called "Future Hospital Commission" which has been promoted by the Royal College of Physicians. In September 2013 this committee issued its first report and I think it’s worth discussing.

For starters, it seems appropriate to pick up the 5 challenges that hospitals are facing nowadays according to a previous Royal College of Physicians’ report:

1. Increased demand in an environment of reduced number of hospital beds
2. Case mixe’s gradual and persistent advance towards chronic diseases and geriatrics
3. Difficulties of coordination and continuity of services for admitted patients.
4. Services of uneven quality in the evenings and at weekends
5. Imminent crisis of professionals and training of new professionals

To face these challenges, according to the "Future Hospital Commission", the hospitals should consider reorganization based on the following principles:
  1. Safe, effective and compassionate medical care for all who need it as hospital inpatients.
  2. High-quality care sustainable 24 hours a day, 7 days a week.
  3. Continuity of care as the norm, with seamless care for all patients.
  4. Stable medical teams that deliver both high-quality patient care and an effective environment in which to educate and train the next generation of doctors.
  5. Effective relationships between medical and other health and social care teams.
  6. An appropriate balance of specialist care and care coordinated expertly and holistically around patients’ needs.
  7. Transfer of care arrangements that realistically allocate responsibility for further action when patients move from one care setting to another.

I think this new report is important because it goes beyond the usual rhetoric and dares to make organizational proposals to achieve the desired changes:

Note how, with the patient at the centre, 40% of the chart deals with community services (areas in light green); two shared areas (in dark green): one for integrated specialized service and the other, for intermediate services (specialist care in the community and complex transfers). As for the hospital sections (blue areas), there’s a centralizing medical division, capable of direct management of wards and of all the clinical use resources of the hospital (except for mother-child sections and certain specialties). This bold organizational proposal aims to reduce "factions" and thus provide the basis for better managing of service continuity. 

At least it seems that the traditional pyramid graph (remember?), where primary care is at the base and the hospital at the top, has evolved into a circle around the patient to convey a more comprehensive view of the different actors in the system. However, the Royal College of General Practitioners lacked the time required to critique it but said the view overly focused on the hospital and, in an editorial, demanded to be included in the commission.

A couple of important concepts of the document (in my opinion):

From the perspective of the medical division, the hospital must be reorganized from bottom to up. At all times, they should take turns to ensure the quality of the provided service and therefore the different model shifts for mornings, evenings, and weekends / holidays / nights should disappear. The duties should become a thing of the past. 

There are two major clinical pathways for the patients: the generalist where the general approach of the patients’ needs, with occasional support from specialists predominates and specialisation for those patients who have a very specific and standardized requirement. Therefore, the concept of hospital beds allocated to medical service also becomes an antique idea.

In conclusion 
The "Future Hospital Commission" report is a 214 page document so logically; this post is not intended to summarize it. I simply dared to highlight a few issues such as challenges, principles and model that I felt were relevant. If you don’t have time to read it all, I recommend taking a look at the "Executive Summary" (8 pages).

Jordi Varela

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