In defence of small hospitals

Trafford Healthcare Trust is known as the birthplace of the NHS, after it was chosen by Nye Bevan to launch the NHS in 1948. But having struggling for a number of years to develop a viable financial plan, the £90m turnover trust was absorbed by Central Manchester University Hospitals Foundation Trust on 1 April 2012.

If you can avoid the dissolutionment that comes with seeing the repeating cycles of reform in the NHS, you can almost be relieved to know that it will all come back round. We all knew for the last 10 years that private finance initiative was unaffordable – it’s just that it became accepted truth that it was the only way forward. 

Read Sarah Davies and Heather Rawlinson on Manchester’s maternity reconfiguration

In fact when the Trafford board was told there was no public dividend capital and we had to use a private finance route to rebuild Altrincham Community Hospital, it meant it was PFI or nothing. That is, until the next government came in and told us that we had to re-do the business plan mid-procurement because the only route was – yes – public capital.

Unbelievable truth

So now I’m thinking that it is time to challenge another accepted truth, another truth that has been perpetuated for the past decade: that bigger is better, is cheaper, is safer. 

When I became chair of Trafford in 2006 it was in a bit of a mess. The previous year we had misdiagnosed a number of mammograms, wrongly giving 28 women the all-clear. We were constantly in the headlines for the wrong reasons. There was an underlying weakness of clinical controls. We were missing most targets and failing to achieve financial balance. Not only were we a poor quality hospital, we were an overspending one.  And when we tried to improve the quality of care by closing isolated geriatric in patient wards in a community hospital, the community had so little faith in us that they took us to judicial review.

‘It is time to challenge another accepted truth: that bigger is better’

It took five years and a high quality executive team and board to turn it around. One of the scariest things I heard when we first started was one of the consultants saying, “There is no point is suggesting anything, because nothing ever changes.” 

With the right leadership we were able to work with all the staff to help them make improvements and deliver a high quality hospital. By 2009 we were named Dr Foster medium size hospital of the year. By the final year of Trafford Healthcare Trust we were the second best general hospital in the country for elimination of MRSA – having three years infection free. We were the second best hospital in the country for referral to treatment times. We were one of the leading hospitals in the North West for day-case surgery, achieving over 80 per cent. 

Our staff led the way on designing pre-operative exercise routines for patients coming in for hip and knee replacements, radically reducing the length of hospital stays and improving outcomes and recovery times. We were one of the few hospitals in Greater Manchester who consistently hit our A&E targets. I honestly believe we were (and it still are) a very good district general hospital, delivering high quality care to its local population.

I have heard all the arguments that bigger is better. That in order to get the best quality care, staff need to be exposed to a wide range of conditions which they don’t often see is small hospitals; that clinicians need to specialise to be the best they can be in their particular area. And of course I agree. If I have a stroke, or a heart attack, or multiple injuries from a car accident, or extensive burns, please take me to the specialist hospital. In fact, this is just what the ambulance service already does. It assesses the patient’s condition and takes them to the most appropriate hospital.

The beauty of small

But if I am a worried parent, a confused elderly person who has suffered a fall and broken something, have my diabetes out of control or am suffering from a sports injury, what I need is a good district general. Especially if I have a number of long-term conditions which I am already being treated for. All the consultants in Trafford know each other – it is the advantage of a small team. It means that treating patients with a number of conditions becomes easier because communication is better. And it creates a better learning environment too. The North West Deanery junior doctors’ survey consistently ranks Trafford as one of the best learning environments for junior doctors, because they get to see people as a whole, not get siloed into working in narrow specialisms. 

The environment is better too. New huge hospitals are impersonal, difficult to navigate and can be very challenging if you are unable to walk the miles of corridors. At Trafford you have windows and doors that open to bring in fresh air, and staff and volunteers stop to give directions and help out visitors. Most of the staff live locally and are proud of their local hospital. Although it might be cheesy to say, it is a friendly hospital. All the public health evidence shows that treatment and recovery isn’t just about clinical intervention – it’s about how you feel as a patient. Small hospitals have a lot of advantages when it comes to creating caring environments.

‘If I am a worried parent, a confused elderly person, have my diabetes out of control or am suffering from a sports injury, what I need is a good district general’

But I haven’t mentioned money yet, and I know that the challenge will be that we can’t afford small hospitals. In fact, Trafford never balanced the books and repaid its historic deficit of £7m. I have two responses to this. First, it is wrong to believe that the NHS is a free market which has demonstrated through the laws of competition that small hospitals aren’t viable. For a start, tariff and payments are set centrally. And in 2009 Trafford was the only hospital in the North West to have the market forces factor applied – taking out £7m arbitrarily from our income. Surprisingly no one could explain on what basis or formulas or even for what reason this had been done.

Second, over the last six years we have had services withdrawn in the name of saving money, improving care closer to home, and lack of qualified staff to cover rotas. The big foundation trusts divide up the services between them, fighting the battle that has become service reconfiguration. Cost savings are just another tool in the armoury. When a neighbouring FT cancels consultant cover for a paediatric service with immediate effect because it has not got what it wanted, you have to start wondering what kind of monster we have created? What happened to putting patients first?

Making it better?

The last service Trafford lost was maternity. I supported the Greater Manchester ‘Making it Better’ reconfiguration of maternity services because I believed it when we were told it would be better for women. Although we wouldn’t have inpatient maternity services at our trust, NHS Trafford would explore setting up a midwife-led unit and we would be able to expand the options open to women, including increasing the number of home births. 

The reality was that the commissioners decided there was not a case for a midwife-led unit soon after our maternity service closed.  Despite a new £20m maternity unit being built at one of the neighbouring trusts, it was closed for deliveries nearly every other day in the first year as it was full. The local supervisor of midwives described to me walking into the reception of one maternity hospital and seeing women in labour waiting to be found somewhere to go. 

Now I am not so ready to believe it when I am told closing a service and concentrating in a smaller number of larger hospitals will provide the quality of care, or care closer to home, or even the financial savings that are promised.

‘As soon as it is downgraded the effect on other services in the hospital will be catastrophic’

That’s why I am supporting the campaign to keep Trafford’s A&E service open as a fully functioning department. We all know that as soon as it is downgraded the effect on other services in the hospital will be catastrophic. There will be no need for the ICU (which by the way has state of the art equipment, being refurbished only last year); there will be risks to surgery because there is a lack of back-up; and people will stop coming to A&E because they will think it is shut anyway, so closure of the whole hospital eventually becomes inevitable.

We are told that there aren’t enough middle grade doctors to keep the A&E open. Well there is a national shortage of middle grade doctors for A&E – it is not just a THT problem. Let’s solve that. If doctors need to get more experience of a range of rare conditions, let them do rotations and work in networks. Don’t let us rearrange patient services around the profession, it should be the other way round. What is the phrase, “nothing about me without me”?

Full up

Finally, Trafford is full. Its A&E is full. It is a good quality hospital, providing good quality care to its local population. I don’t know where all these patients are going to go. We have been hearing for years that we don’t need so many hospital beds because we can care for people at home. But what we see is creaking community and social care services, barely able to keep up with demand.  There is no evidence that the people in Trafford Healthcare Trust can be cared for at home or in the community. 

I am not prepared to just accept the given truths anymore about the future of healthcare in this country. We need to think again. If we want to keep the NHS that Danny Boyle reminded us we were so proud of in the Olympic opening ceremony – we need to start asking questions.

Fay Selvan was Chair of Trafford Healthcare Trust from 2006 to March 2012