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bmj.com Analysis • NHS in the age of anxiety: rhetoric and reality—an essay by Rudolf Klein (BMJ 2013;347:f5104)

HOSPITALS WITHOUT WALLS

A new report from the Royal College of Physicians suggests a radical approach to the problem of
providing continuity of care for modern patients. Nigel Hawkes examines the details

N
othing galvanises a community so sation and improved outcomes but at the cost of ership options for generalists. It envisages hos-
much as a threat to its hospital. For fragmenting services and trapping patients inap- pitals organised on a “hub and spoke” pattern,
better or worse, hospitals embody propriately in locations where it is hard to meet with an acute care hub housing a single unified
the reality of the NHS for most peo- all their needs. Targets such as the four hour wait medical division that will assume responsibility
ple in a way that general practice, in emergency departments can often result in for the care of all patients (except for paediatrics,
let alone community care, cannot match. They patients being moved to a ward, any ward, as the obstetrics, and possibly some specialised surgi-
are as important to a local sense of wellbeing as limit approaches, rather than to the right ward— cal wards). The medical division would be run
churches used to be, and defended with all the delaying specialist opinion and increasing length by a chief of medicine, an experienced physician
fervour that once filled those empty pews. Yet of stay. The payment system in the English NHS who would assume budgetary and administra-
hospitals are not the solution but the problem, has caused an overemphasis on elective rather tive responsibility for care in the hospital and the
according to a new report from the Royal Col- than acute care, while the purchaser-provider community, using pooled budgets. The chief of
lege of Physicians (RCP). “Conventional models split has, says the report, undermined joined up medicine would report professionally to the hos-
of health service design in which a hospital site working between secondary and primary care. pital’s medical director and operationally to the
is the sole focus for the delivery of emergency, chief executive.
acute and elective services are dated,” it says.1 Rise of the generalist “Working with a shared culture and objectives
They cannot provide the integration, collabora- The report believes that the future hospital will across all medical speciality teams, the chief of
tion, communication, and information sharing need more generalists and fewer specialists. It medicine will motivate staff to provide care of
needed to care for today’s typical patients, who says: “The expectation that most physicians will the highest quality to patients, irrespective of
are elderly, multiply morbid, dependent, and become highly specialised in a narrow field must their work base—hospital, community—or area
often confused. The circumstances that made be changed.” of clinical practice, in line with the NHS Consti-
the hospital the icon of care have changed, but Nigel Edwards, senior fellow at the King’s tution and professional standards,” the report
the hospital has not changed with them. Fund, agrees but asks, “Who’s been responsible says.
The RCP’s Future Hospital project is a bold for overall growth of specialties? The RCP has Care would be coordinated from what sounds
attempt to envisage a new role for the hospital. said before that we need more generalists, but I like a war room: the report calls it a clinical coor-
It is one in which physical and mental barriers haven’t noticed we’ve produced them.” dination centre. Twice a day, seven days a week,
dissolve: the walls that trap clinicians inside Recruiting doctors to a generalist role (in either clinical teams would meet here to coordinate
buildings and within professional silos are elim- acute or general internal medicine) is increas- care in the hospital and in the community for
inated. Care is delivered where patients’ needs ingly difficult, the report admits. The workload of their patients. Displays would show electronic
can best be met, by medical teams Care would be medical registrars is heavy; a quar- patient records (the failure to share these records
working with professionals from
coordinated from ter of them describe it as unmanage- so far is “incomprehensible,” the report says)
primary and social care. Expertise able. Most feel a lack of leadership, together with standard clinical referral, diagnos-
is available seven days a week, both
what sounds like with nobody to report problems to. tic, and management protocols for all common
in hospitals and in the community. a war room Yet these doctors make the key deci- patient groups.
In the report’s words: “The overriding objective sions about new hospital admissions: which spe- Other displays would show in real time
should be continuity of care for patients, coor- cialties patients should be referred to, their care where patients are, together with information
dinated and delivered by a single consultant-led pathway, and their discharge. “It’s an extremely about their admission, discharge, and transfer
clinical team.” The hospital ceases to be “some- crucial job and it requires skills every bit as great of care, as well as data on community services
where”; it becomes everywhere. as any specialist,” says Edwards. “But there’s and bed capacity in interim or care homes. Moni-
“We went through the report removing the no private income option and the workload is tors would show inpatients’ vital signs, enabling
word discharge wherever we could,” says Profes- heavy.” He argues that clinicians who do the job untoward events or near misses to be identified
sor Timothy Evans, who chaired the RCP group should be paid “extremely well,” with an exit early. Telephone and email helplines for patients
that produced it. “What our patients want is strategy into other roles such as management in and professionals would be staffed seven days
continuity of care, wherever they are.” Maybe, their mid-40s before burnout strikes. a week, linked to primary care, so that, as the
he added, some GPs will find the implication report puts it, “responsibility for care will thus
that they are not already providing such care New model of care be shared between patients and practitioners in
inflammatory—“but I hope not.” The report says general internal medicine should hospitals and primary care, and continuously
The RCP’s vision runs counter to many pre- be promoted as a valuable and attractive career supported by a virtual dialogue.”
vailing pressures. The intense focus on the option but does not say exactly how. Its vision There isn’t a hospital in the NHS that works
treatment of specific conditions, such as heart of future hospital services would, however, go like this nor, Evans believes, any international
disease, stroke, and cancer, has driven speciali- some way towards supplying career and lead- example either. He acknowledges that there

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 FEATURES

RCP vision for future care

Care should come to the patient, not the patient
to care
Patients should not be moved unless it is
absolutely necessary for their care
Patients should not be “discharged”—care
should be seamless in and out of hospital
Care should be provided seven days a week, with
a named consultant in charge
Hospitals should establish a medical division,
under a chief of medicine, with responsibilities
that extend into the community
More generalist physicians will be needed to
manage patients both in hospital and in the
community
Care will be run from a clinical coordination
centre, which will act as a central control room
with a “chief resident” responsible for planning
the design and delivery of services, including
rotas
Payment systems such as payment by results and
the purchaser-provider split should be reviewed
to reduce the overemphasis on elective surgery
The report favours a “hub and spoke” model of care
would have to be changes of function at various based on technical aspects of the surgery and estimate the costs of acute care. Providers have
hospitals to accommodate this system of care, post-operative complications,” the report says, expanded elective care because the price per
raising the dread word reconfiguration. adding, “This arrangement will have major unit is strong and largely volume based, while
Edwards says that those who recommend implications for surgical trainees—with all but acute care is usually part of a block arrangement.
hub and spoke models of hospital provision are the more senior trainees redeployed to physi- “It is crucial that these funding anomalies are
always those who will be working in the hub— cian-supervised duties and realigned to medi- resolved,” the report argues.
while those relegated to the spokes, which stand cal training programmes.” The message is clear: Williams, who chairs the Academy of Medical
to lose some services, may be less enthusiastic. surgeons should be on tap but not on top. Royal College’s working party on seven day care
“The risk is that the moment you can’t run acute Norman Williams, president of the Royal and was a member of the steering group for the
medicine in the spokes, the requirement to find College of Surgeons, bridles slightly at the RCP report, agrees that there needs to be a switch
space in the hub is huge,” he warns. “But it implications of this. “Surgeons are more than of emphasis away from elective targets. “Every-
depends what you mean by spoke.” He says technicians,” he says. “I think it would be body recognises that,” he says. “The problem is
there are examples, such as Heart of England extremely dangerous to leave all postopera- that if we concentrate more on emergency and
NHS Foundation Trust, that he believes have tive care to physicians. Time and again juniors acute work, keep the same staffing, and don’t
made it work. think postoperative problems are medical but reconfigure while having consultants working
Evans’s response to this is to say that there an experienced surgeon can often see they’re more at weekends, then that will affect elec-
won’t be such a clear distinction between hub not.” He cites the example of urinary symptoms tives.” Like the report itself, he is unsure where
and spoke. “We’re all going to be in the spoke,” after colon surgery, which could be infections the money is coming from to make these changes
he says. “It’s hard to think of an example, except but could equally be the results of bladder dam- possible, but he agrees they are necessary.
possibly intensive care, where more commu- age. That said, he adds that in treating fractured “Many of the recommendations it makes are
nity care couldn’t be delivered.” And he says neck of femur, close cooperation postoperatively very important and we support most of them,”
that there is no intention of imposing the same between surgeons and physicians had produced he says. “It’s ambitious, but that’s appropriate,
model everywhere. ”One size doesn’t fit all,” he fantastic results. “But that’s a very specific too. We all agree that the patient should be at the
says. “You can’t close a hospital in East Anglia if case—other specialties are different.” heart of the care we deliver and if you’re a patient
there’s only one there.” you don’t have any doubt that 24/7 working is the
Funding questions way. But we’ll need to get there in stages, and with
What about surgeons? The report is largely silent on where the money the best will in the world, it’ll take some time.”
Some surgeons may cavil at the diminished role would come from or, indeed, how much the plan Nigel Hawkes freelance journalist, London, UK
they occupy in the RCP’s new vision. Once the would cost. That’s a future project in a continu- nigel.hawkes1@btinternet.com
surgeon has operated, most of the problems ing programme of work, Evans says. Some would Competing interests: None declared.
today’s elderly patients face are medical, not come from shifting the emphasis for elective care Provenance and peer review: Commissioned; not externally
surgical, the report argues. Patients on surgi- to acute and emergency care—which has been peer reviewed.
cal wards should be under dual supervision “chronically underfunded” according to the References are in the version on bmj.com.
of physicians and surgeons. “Consultant sur- report—but that would need reform of payment Cite this as: BMJ 2013;347:f5479
geons may provide a more consultative service by results, which tends systematically to under-  NEWS, p 1; EDITORIAL, p 7

BMJ | 14 SEPTEMBER 2013 | VOLUME 347 19

PATIENT DATA

bmj.com
 Features: Sharing data from clinical trials: where we are and what lies ahead
(BMJ 2013:347:f4794)
 Campaign: The BMJ Open Data Campaign www.bmj.com/open-data

MEDICAL DATA
Does patient
privacy trump
access for research?
Patient data are powerful tools for medical research, but, as
Adrian O’Dowd reports, plans to increase access are raising
questions about how to ensure privacy

A
national drive to gather and store “Recently people have got a little bit worried “There will be a very small percentage who
more information on patients—both about the government saying that it is going to will object, but the vast majority, if they know
medical and genomic—is under way. exploit NHS electronic health records as a way what it’s going to be used for—ie, legitimate
At the same time, researchers are on of making money by selling them to industry to research for the benefit of humanity—will not.”
the brink of accessing individual do research on. However, he is concerned about the public’s
patient data from the vaults of drug companies’ “But the GP research database has been lack of knowledge about NHS England’s plans
clinical trial records. But with this fundamental around for a couple of decades and, quite cor- for care.data: “It’s down to communication and
shift comes a new concern: how can we make rectly, we sell that information to drug compa- the opt-out. Patients are entitled to opt out,
best use of individual patient data without nies who use it to do observational epidemiology but it’s being buried. NHS England, in the first
impinging on privacy? In the wider world, research into potential risk signals.” place, did not want the opt-out at all.
recent cybersurveillance scandals have led to In August, NHS England announced it was “NHS England talks about a digital NHS and
a new nervousness about privacy. For patients commissioning the Health and Social Care that lots of things will be on the web and you
the concerns are that their privacy is protected Information Centre to run the care.data service, can download your medical history, but the
and that data are not used inappropriately or which is designed to make better use of the posters and the leaflets for care.data contain
mischievously for the wrong reasons. information in general practice patient records, no URLs. They suggest you talk to the recep-
All three potential sources of medical data including data such as referrals and NHS pre- tionist about how we use your medical records.
for research in the UK—a data service provid- scriptions. Data from general practice will be There are some GPs that are actively telling their
ing patient records from general practices and linked to Hospital Episode Statistics, thereby patients about care.data but most won’t.”
hospitals, data from clinical trials, and an NHS transforming it into the Care Episodes Service.
DNA database built from patients’ genomic The information centre has worked with the Genetics
information—are proving controversial. BMA and the Royal College of General Practition- The plans to build a DNA database on
Researchers currently get data from patient ers to produce information materials and guid- 100 000 people for the NHS are also causing
records mainly through the clinical patient ance, including for GPs,1 to support practices controversy. The pilot database will create a
research datalink (CPRD). The electronic health and raise awareness among doctors and patients. variant file containing the whole genome of
records given over are anonymised—patients’ Patients who are not happy for their data to be each person minus the reference genome that
names and dates of birth are removed and post- used in this way can ask their general practice to will be attached to the medical record. If the
codes are obfuscated. Ben Goldacre, author and note this in their medical record and can opt out. pilot is successful it will be rolled out to every
research fellow in epidemiology at the London Sam Smith, a technology adviser for cam- person in the NHS in England.
School of Hygiene and Tropical Medicine, says: paigning organisation Privacy International, The Human Genomics Strategy Group
“In my day job I work partly on CPRD data—full says: “I think patients are happy for their medi- report, commissioned by the government
electronic health records of every blood test, cal data from general patient records to be used and published last year, says: “Genomic
every prescription, every diagnosis—for obser- by bona fide academic researchers in a university technologies have the potential to transform
vational epidemiology. if they are asked. the delivery of healthcare in the UK, provid-

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 PATIENT DATA

Can anybody tell me from an ethical point of view, why the

true effectiveness of a treatment can be outweighed by the
potential that somebody will be identified in that process?

As well as the more general clinical study “There is a concern that data will be used irre-
reports, researchers also want access to indi- sponsibly and that’s why we have put in place
vidual patient data—information about trial the system of review of the protocol or the ques-
participants such as blood tests and dates of tion to be asked such that we look and make
hospital admissions. sure that there are statisticians and capable peo-
Goldacre says accessing individual patient ple involved in the team who are going to look at
data needs careful consideration: “For clini- it and interpret it,” says Shannon.
cal study reports with personal data removed, Anonymising patient data properly is not
summary results, and for registration, there is straightforward, argues Shannon, who says:
no ethical argument at all against making all “It’s a very important element that whenever we
of that information publicly accessible for all release clinical trial data, that we respect the pri-
the trials. For individual patient data, there is vacy of the patients who participated in the trial.
a world of caveats and structures and mecha- “We have put in place a system where we
nisms that need to be discussed.” anonymise the data and then we throw away
But Goldacre is clear on the benefits of access the code sets so it is theoretically not possible
to individual patient data: “When it comes to to go back to the individual.”
sharing individual patient data, there are many The European Medicines Agency is also looking
more opportunities. We can try to identify sub- at this issue and, in June, released its draft policy
TEK IMAGE/SPL

groups of patients who do better or worse on a on publication and access to clinical trial data.4
particular treatment and then target our inter- Plans within its consultation, which runs
ventions so that people get treatments that are until 30 September, if implemented, will allow
likely to do them more good than the general researchers access to patient level data to con-
ing vital insights to support more accurate population.” duct and publish their own re-analyses and
diagnosis of disease and inform therapeutic When sharing data with researchers, it secondary analyses.
decisions.”2 should be checked that they are competent to Despite the many concerns over patient pri-
The report recommended that the Depart- protect the information and do the analysis, he vacy, Heneghan says transparency will become
ment of Health, in partnership with the Depart- says. increasingly important.
ment for Business, Innovation and Skills and Carl Heneghan, professor of evidence based “We have got an ageing population and peo-
partners, should establish a central repository medicine at the Department of Primary Care ple with more chronic disease and disability,
for storing genomic and genetic data with the Health Sciences at the University of Oxford, and it’s going to cost more money,” he says. “We
capacity to provide biomedical informatics agrees there are worries about patient privacy have got to save money and we cannot afford
services. when dealing with clinical study reports and very costly treatments that don’t have much
In addition, there should be agreements individual patient data. benefit and don’t declare the full effectiveness
that require data from tests carried out by NHS “They do contain what people consider for our healthcare system.”
commissioned laboratories to be made avail- is identifiable data, such as age, sex, and an He believes that the argument is not just
able to nationally designed research databases event,” he says. “There is a remote possibility financial but ethical: “Can anybody tell me from
but ensuring patient confidentiality and data that you could put information together and an ethical point of view, why the true effective-
protection. work out what was going on, yet I’ve never seen ness of a treatment can be outweighed by the
GeneWatch UK, a not for profit organisa- anybody do that and never seen anybody want potential that somebody will be identified in
tion that aims to ensure genetic science and to do that or attempt to. that process? Are they prepared to let people die
technology are used in the public interest, is “If you don’t know all of the data, you can- on the basis that somebody may be identified?”
worried the proposals will create privacy prob- not come to a decision about the effectiveness Adrian O’Dowd freelance journalist, London, UK
lems. It says such a database could mean that of treatments and how it’s going to work in clini- adrianodowd@hotmail.com
a person’s employer or a drug company could cal practice. If you don’t know all of that, you Competing interests: None declared.
be classified as a researcher and thus gain shouldn’t be using the treatment.” Provenance and peer review: Commissioned; not externally
access to data about people who have had a GlaxoSmithKline has pledged to make all peer reviewed.
workplace related illness or an adverse drug its clinical study reports publicly available on 1 Health and Social Care Information Centre. Care.data
guide for GP practices. www.england.nhs.uk/wp-content/
reaction and work out their identity. its register and is opening its platform for con- uploads/2013/08/cd-guide.pdf.
trolled access to patient level data. 2 Human Genomics Strategy Group. Building on our
inheritance: genomic technology in healthcare. www.gov.
Trial data James Shannon, the company’s chief medi-
uk/government/uploads/system/uploads/attachment_
A potentially major new source of patient data cal director, says one worry for companies and data/file/213705/dh_132382.pdf.
is from drug company clinical trials. Pressure academics is that making data more widely 3 BMJ open data campaign. www.bmj.com/open-data.
4 European Medicines Agency. Publication and access to
has been building over the past few years for available could mean journalists could trawl clinical-trial data. www.ema.europa.eu/docs/en_GB/
drug companies to provide more data, includ- through results and come up with unfair and document_library/Other/2013/06/WC500144730.pdf.
ing from the BMJ’s open data campaign.3 sensationalist conclusions. Cite this as: BMJ 2013;347:f5516

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