Hospitals must shrink or shut, doctors warn

GPs' leader Dr Michael Dixon says half of services should be moved closer to patients' homes

GPs who now control much of the NHS budget have said many hospitals will have to drastically shrink or shut altogether because half their services should be provided elsewhere. Family doctors have raised questions over the future of hospitals by claiming services would improve if large swaths of medical care – including diagnostic tests, outpatient appointments and dementia care – were carried out closer to patients' homes.

Dr Michael Dixon, who represents many of the 211 clinical commissioning groups (CCGs) that last week took control of £65bn of health spending, told the Guardian that hospitals would have to downsize as part of efforts to cut what he said was "an awful lot of fat" in the NHS budget and make healthcare more patient-friendly.

Dixon cited the example of frail elderly patients, who occupy about 70% of hospital beds and who could be looked after at home by teams of community-based health professionals.

He signalled that CCGs intend to use their new roles as key decision-makers in the NHS in England to drive through radical changes to how healthcare is delivered, especially hospital services. "A very large amount of what's currently done in hospitals could or should be done elsewhere. I think 50%," said Dixon, the interim president of NHS Clinical Commissioners, which represents 135 of the 211 CCGs.

Asked what would happen to hospitals if they provided increasingly fewer services, he replied: "The implications are that hospitals would need to downsize and become places where you go if you are very ill or need very specialist care and not places where you go for more generalist care or where you can be looked after in the community."

Pressed on whether that would mean hospitals had to slim down, close or both, Dixon replied: "Both. [The aim should be to] hopefully bring down [their number] rationally by some of the commissioning groups coming together and deciding how that is best orchestrated." He said GPs needed to push through a revolution in healthcare to stop the NHS coming under "unsustainable" pressure due to the rising demand for treatment caused by ageing.

He acknowledged they risked becoming unpopular with patients by doing so if that led to the loss of highly valued local hospital units.

"CCGs are up for it. But [doing] this isn't everyone's cup of tea … because it's at a high level and it's politically difficult. We are used to being loved by our patients and having 90% trust and all the rest of it." CCGs would need "considerable protection and support" to implement necessary changes, Dixon said.

The British Medical Association, which represents most of Britain's doctors, accused Dixon of threatening the NHS's ability to provide a full range of health services to patients. "Patients' needs, and the ability of the NHS to meet them, change all the time. It is right that we regularly review services and where they are provided," a spokesman said. "However, taking an arbitrarily defined chunk of services away from hospitals would threaten their financial stability, and therefore the ability of the NHS to provide comprehensive specialist care."

The BMA also made clear its view that changes to the services hospitals offered should only occur gradually and not until alternative services had been put in place, which would require a redirection of NHS resources.

"The answer is not revolution but a rational, long-term approach to the planning of services. Any changes should be based on clinical evidence, not cost-cutting grounds. It would also require general practice and community care having the necessary resources. There would need to be adequate investment in these settings before any change to the funding of hospitals," the spokesman said.

But Dixon's views gained the backing of Mike Farrar, chief executive of the NHS Confederation, which represents hospitals.

"As a vision for what the future in healthcare could be like, it's right," Farrar said. "The public's attitude to hospitals needs to change. We need to explain to people that there are better ways in which we can care for people and that the aim should be to keep people living independently out of hospitals for longer. But to do that we need to take some of the money that goes into hospitals and put it into primary care and community care services instead."

The pressures caused by ageing and the growing numbers of people with one or more long-term conditions meant radical changes to hospitals were needed, Farrar said. "This is a difficult journey but it's one the NHS has to make. A good analogy is that until the 1980s people with mental illness and learning disabilities were looked after in hospitals and then there was a big shift of care into the community. That was controversial at the time but is now, years later, recognised as having been the right thing."

But he said many hospital staff would have to start working in non-hospital settings to make the new forms of care work for patients, and many may not want to do that because they are comfortable where they currently work and would need extra training to perform their roles elsewhere.

The Royal College of Physicians, which represents hospital doctors, also offered partial backing to Dixon. It had recognised last year that "hospitals are struggling to cope with the challenge of an ageing population and increasing hospital admissions." A spokeswoman said: "All too often hospital buildings, services and staff are not equipped to deal with the increasing number of older people being admitted to hospital with multiple, complex needs, including dementia." Its Future Hospitals Project is examining how more care can be provided in community settings.

A spokesman for NHS England said: "There is no doubt that delivering the best possible care for patients at a time of economic austerity is going to be very challenging and that we need to adapt the way that services are delivered in order to provide the best possible to today's patients. It is really important that there is a full debate about these issues. It is also really important that our new GP commissioners are ready to lead this debate with us. We need them to help the NHS face its strategic challenges and the difficult decisions that will in some cases be involved. We therefore welcome Dr Michael Dixon's contribution to the debate."


Denis Campbell, health correspondent

The GuardianTramp

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