A model for the next millennium

Howard Goodman describes a design for the acute 'hub' often cited as the focus of care in the future, which was overlooked in a recent scheme for a London trust, but which has great potential within the current climate of rationalisation.

We are now in the midst of a number of acute trust mergers, some of them quite traumatic, whilst at the same time being uncertain of what they are intended to achieve. Are they essentially cost saving measures which will reduce management costs - a more structured approach to what was inevitable in any case? Or are trust mergers envisaged as a way of bringing together all major clinical specialties in one location in order to achieve a comprehensive service for the patient? The White Paper on primary care trusts also seems equally uncertain as to its aims. Is it a concession to GPs who are no longer fundholders - is it a genuine attempt to involve local interests in developing their local services? What seems to be missing from both these developments is some linking strategy to provide locally what should be provided locally and provide centrally what should be central.

But serendipity or perhaps luck, may play a part. These two apparently disparate policies can effectively provide a solution to a number of current problems. The need to create a critical mass of clinical services centrally to support a trauma centre in lieu of smaller A&E departments, together with the realisation that many services are best provided close to home can offer a model which may be generally applicable.

THE CONCEPT

The concept of this model; often referred to as `hub and spoke', has been discussed for several years. There was apparent support for this principle in reports by both the BMA and NAHAT although their views on numbers varied. Vetter in his recent paper spoke of one million as the desired catchment population. Our research shows that however desirable it is, a model based on these larger numbers cannot be easily achieved. However little seems to be lost if the overall catchment area is 600 000-700 000.

The key to the efficient delivery of care in this model relies on two factors; a common staffing structure at all levels and the maximum sensible use of information technology. The same consultants would hold clinics, both at the central and the locality hospitals and even when not present locally, accessible by telemedicine. Senior management would be common, avoiding duplication in issues such as purchasing and hotel services but with local management handling day-today matters.

THE REALITY

In a `real-life' situation this seems straightforward. Locally those services used by the majority of people are close to their doorsteps, particularly as, for example, consultants come to them rather than vice versa. These locality hospitals would provide for outpatient consultations, a minor injuries unit, rehabilitation, obstetric services for low risk cases and day surgery for the great majority of elective procedures. There would be a small bed component for longer term care and support of primary care.

At the central hospital the concentration of clinical skills would allow all emergency work and the most complex of elective work ie that requiring a high level of expertise or calling upon sophisticated and complex equipment.

Thus it is envisaged that the central hospital might be configured as a surgical hospital, a medical hospital and a women and children's hospital.

Tertiary care could be grouped as a series of 'institutes' for neurosciences, cardiology, cardiac surgery and oncology. Each would have its own integrated research function but share the teaching facilities where these apply. Hotel services, purchasing, supplies and disposal and energy provision would be common, as would PGMC, recreation and restaurants.

It is essential the central hospital does not become a `mega-- hospital' with all the impersonality and lack of patient-friendliness that can arise. By the institutes having their own identity and even own front door, a personalised atmosphere can be achieved.

WARDS

The ward configuration would replace the historic finite subdivisions with a more fluid relationship where beds would not be exactly allocated to individuals or specialties but would open the way for `organ grouping' eg, gastroenterology, nephrology etc. To achieve this, bed areas would be contiguous and would consist of 50% single rooms, all ensuite, the remainder in four-- bed bedrooms, also ensuite. This configuration will not only give a degree of patient choice but also accommodate cross-infection should this occur.

THE MILLENNIUM HOSPITAL

Perhaps the most recent and best developed example is the Millennium scheme for University College Hospital at King's Cross. Originally conceived as an academic exercise, the study hypothecated a major acute hospital serving, perhaps, 600 000 people supported by a number of locality hospitals serving 70 000-100 000 people. It was only when the researchers looked for a project which might provide a theoretical model that the UCH scheme surfaced. Other members of the team had been looking at derelict railway land in Camden for other purposes and the existence of an available site moved the idea from the theoretical to the practical. The scheme for UCH remained remarkably true to the model and envisaged a new 'campus' style hospital at Camden supported by six or seven locality hospitals including the Whittington, and importantly, Bart's in the City. All of these would have some beds, day surgery, outpatients, simple imaging but sharing a common staff, purchasing and information technology.

It is fair to say that, although we believe that the King's Cross project has considerable advantages over the current scheme at UCH which it might replace, it is not liked by the UCH planning team who seem to prefer a 17-storey tower on the Euston Road. Firstly, the King's Cross site is very accessible being close to two mainline stations, the underground and bus routes. Indeed if an existing, but closed, underground station was reopened it could have this on site. Because of this, as envisaged the design presumes almost no car access. Indeed the only vehicle accesses are A&E and commercial deliveries. Apart from very few essential users there would be no need for car parking.

Secondly, although the site is derelict it is generous in size, bounded by a canal and, subject to one or two listed buildings, allows the optimum flexibility in layout. Perhaps the biggest advantage of all is that it allows a low-rise building which can be built in one phase. Beds overlook the water and the listed buildings are incorporated, with considerable visual advantage, into the design. Despite all the advantages the scheme will not get far unless it is competitive on cost. Our preliminary costings show that in capital terms there are considerable savings and although current revenue costs are difficult to confirm we believe that it is in this field that there is the potential for major reductions.

But is what is good for Camden good for other communities? The designers of this scheme think so. The Camden project was a reaction to a very difficult problem of replacing a major teaching hospital in London, with all the concerns of skewed populations and decreasing catchment areas.

Given the challenge of merged trusts in urban or suburban areas and pressures to close community or cottage hospitals this model becomes even more valid. Most merged acute trusts produce populations of 500 000 or so. This is the minimum viable for the mix of clinical services envisaged, more importantly it represents the near optimum for A&E services and a trauma centre. The existing community or cottage hospitals then assume the role of locality hospitals providing all or most of those services listed previously, giving, importantly, the same quality of service because of shared staff, easier access and a 'casualty' service for all those who, properly, do not need A&E.

Is this a universal model? Probably not. Rural areas might not accept the distances that this model would impose on accident services and the remoteness of the central hospital, although recent experience in Wales with telemedicine seem to challenge this view. But hybrid versions have been developed which meet these issues but making a virtue of the `split-site' DGH (one elective, one trauma), and enhancing the casualty services.

CONCLUSION

Stepping back and taking a national view, what do we see? Far fewer acute hospitals, perhaps a third of those we have now. Far more locality hospitals accessible to far more people. Better quality for the minority of patients who use the central hospital. This same better quality for those who use their local hospitals. More sensible reliance on information technology. All the economies of scale in purchasing and administration. A substantial overall saving to the NHS whilst proving most patients with the nearly impossible dream of high quality services on their doorstep.

Howard Goodman Dip ArchRIBA FlHospE is a senior partner at MPA Healthl Strategy & Planning.

Copyright Wilmington Publishing Ltd. Aug 1998
Provided by ProQuest Information and Learning Company. All rights Reserved