Hospitals and Healthcare Providers: what have we learnt?

Jo Bibby, Director of Strategy and Innovation at the Health Foundation, reflects upon the history and development of healthcare providers.

When one of my sons was trying to decide what to study at university, he was torn between whether to study History or Maths. When I spotted a degree course in History of Maths I thought I might have found the solution but on suggesting it he replied ‘why would I want to study that? It would combine the least interesting parts of history with the least interesting parts of Maths’.

I was reminded of this as I was read the timeline of hospital care in the UK. Starting in medieval times and gaining greater and greater granularity as it progressed I wondered whether it would be of most interest to historians or those who work in healthcare.

Up until the creation of the NHS the narrative followed the broad sweeps of history. Early hospitals were set up by the monasteries which meant that with the reformation they were abolished, leading to the sick being left on the streets. Giving way to public opinion Henry VIII allowed St Bartholomew’s to be re-established and other hospitals followed.  Without the funding from the church, the services would be funded through subscription or donation.  This picked up momentum in the 1700s due to the arrival of the Huguenots in London who imported the endowment-based funding model from France.

With industrialisation came the need to manage and contain contagious disease and the poor law hospitals started to shift from the place of last resort for those no longer fit to work to places where the new medical advances were more systematically applied.

It was the advent of the Second World War and the prospect of large civilian casualties that drove the need to nationally coordinate the provision of care. And this period provided the foundations for our current NHS. 

Once the NHS was established, the timeline becomes less driven by the broad sweeps of history and more by the process of government, bureaucracy and the need for public accountability of a state funded service.  However, the NHS was still held in the grip of history with provision varying across the country more because of historical accident than actual need. Enoch Powell in 1961 was perhaps the first politician to grasp that the NHS needed to break free from the past saying: ‘Hospital building is not like pyramid building, the erection of memorials to endure to a remote posterity. We have to get the idea into our heads that a hospital is a shell, a framework, however complex, to contain certain processes, and when the processes change or are superseded, then the shell must most probably be scrapped.’

Yet, we still see the consequences of services struggling to deliver the modern processes of care in shells that were established before the availability of advanced diagnostic techniques, life saving drugs and operations.

For me, history met personal experience when it reached the period of the NHS Plan. At the time I was responsible for performance policy and the implementation of a number of the initiatives that ensued. Most memorable was the production of the first set of NHS Ratings. Initially conceived by ministers as ‘traffic lights’ where Trusts would be given red, amber or green ratings. However, due to the impression such a system would have on public confidence the decision was made to use ‘star’ ratings instead.  The ambition was to have a balanced scorecard approach to assessing hospital performance. However, while there were some early measures of hospital mortality and clinical outcomes, there was an understandable reluctance to use this information for judgement. As a consequence the first ratings were largely based on information such as finance and activity and some HR measures.

As a policy maker it is easy to feel remote from the frontline of care. However, shortly after the publication of the first set of ratings, a chief executive from one of the 3 star rated Trusts recounted a story which made me stop in my tracks. He said he had been approached by a consultant in his hospital who had been discussing treatment options with one of his patients. They had reached an impasse. The patient was reluctant to have further intervention. The consultant thought he would benefit. They had had a number of discussions about the pros and cons, but one day the patient arrived and said he had decided to proceed with the recommended treatment. After having talked through the implications and plans the consultant finally asked the patient why he had changed his mind. He replied ‘well you are a three star hospital now aren’t you? You must be doing the right thing’.

I still can’t recall that story without feeling a deep sense of concern that someone changed their mind about their preferred course of treatment on the basis of an assessment of a hospital’s finance and activity figures. Perhaps the consultant was right, perhaps the course of action was in the patient’s best interests but the thought that maybe it wasn’t, maybe it wasn’t what that specific individual would have really wanted, has never left me.

Now, we are better able to make assessments about the quality of clinical care. The various national clinical audits, the consultant level outcome data, information on infection rates all provide a richer picture of the quality of care provided. Yet, reading the timeline I was struck that the abolition of the monasteries shifted the care of the ill and dying from the spiritual domain to the domain of science and medical advance. There can be no question that this has delivered huge benefits but I also wonder whether we may have lost something in the process?