Closing hospitals with a community spirit: is it possible?

Any idiot can close a hospital but it takes talent, time, and money to improve services in the community. http://t.co/90XFbpW14d
— Richard Smith (@Richard56) January 14, 2014

This week we have a couple of tweets from Richard Smith, former Editor of the British Medical Journal. The first one which is quite persuasive; sends us to one of his articles published in The Guardian where he raises a controversy, since against all appearances, hospital beds have become, in political terms, prevention goods against the spending cuts. But the reality persists, says Mr. Smith, and however you may look at it, the number of hospital beds must be reduced, not to preserve health system resources but to strengthen community services. Closing hospital beds with a community spirit he says, takes talent, investment and time and doing things right. But if this is not done correctly the price can be very high, as treating people in hospitals when they could have been treated at home, is uncomfortable, dangerous and expensive.

Hospitals: 10 necessary structurals reforms

Hospitals are structures with a powerful influence on the overall health system. Its effectiveness in solving certain acute health problems, especially in the surgical area, gives them a major social prestige. However this fact should not undermine two structural problems that are weighing their image down:

a) The first problem is internal. The own bureaucracies are showing signs of fatigue and this affects the service quality, especially when it comes to the safety of admitted patients.

b) The second problem is relational. The hierarchical superiority of hospitals has placed them apart from the communitarian reality and the primary care, and causes now a serious difficulty in dealing, in an integrated manner, with the complex chronic disease care and with the geriatric frailty.

Coordination, integration (in Spanish Health Care System)

Each of the care system levels has become strong in a particular feature in Spain: in primary care, it has been the role of the gatekeeper; in hospitals, the hierarchization of medical services and in the socio-sanitary area, the offer of post-acute beds. And if we look at what these strengths have been translated into, we will rapidly agree that the primary care has achieved a performance of proximity and effectiveness in prevention, the hospitals have obtained very satisfactory levels of resolution in acute diseases and the socio-sanitary has contributed the essential decompression to the system.

These same strengths, which are certainly well recognized, become rigidities when new requirements that somehow question the status quo, emerge. However, I will demonstrate in 4 examples how the health system has been able to offer imaginative responses, without any hassle:

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:

"The Poverty Hypothesis" versus "The Capacity Hypothesis"

The socioeconomic status influences the consumption of goods and services in each community in a very obvious way, a phenomenon which logically includes hospitalisation rates. But in what sense does poverty or wealth determine hospital utilisation? And what role does the accessibility to the number of installed beds in the community play in hospitalisation rates?

To try to answer these two questions I will examine two projects, an English one and an American one that emphasise two different hypothesis, the first one being based on the influence of poverty and the second one, on the installed capacity.

The English analysis. Hypothesis: poverty is crucial

This paper uses as a clinical measure, a closed list of 19 "Ambulatory Care-Sensitive Conditions (ACSC )", such as heart failure or diabetes complications that should not be a reason for admission if primary care had the capacity to globally treat these patients. Regarding the assessment of poverty, the study uses a socioeconomic quintiles index measuring various deprivations (Index of Multiple Deprivations: IMD 2010).