RM Temple

Acute physicians are confronted daily by the relentless increase in clinical demand, inadequate continuity of care, breakdown in out of hours care and a looming crisis in the medical workforce. The scale and gravity of these factors, together with changes to patient’s needs relating to the ageing demography, were detailed in the RCP report published in September 2012 ‘Hospitals on the edge’. The top concern of RCP members and fellows was the lack of continuity of care, ahead of financial pressures and clinical staff shortages. Worryingly one in ten physicians stated they would not recommend their hospital to a family member, and a further 25% were ambivalent on this question. Concern about the provision of acute medical care is not confined to consultants and specialist registrars. Another RCP report, ‘Hospital workforce, fit for the future?’ (2013) highlighted that 37% of FT2s and CMTs considered the workload of the medical registrar on call ‘unmanageable’.

The outcome of the Mid Staffs independent inquiry in February 2013 provided critical context for the launch of the Future Hospital Commission (FHC) report, which was launched seven months later in September. The report was met with an extremely positive response from patients, carers, NHS staff, healthcare leaders and politicians. Lancet Editor Richard Horton said that the Commission had ‘produced the most important statement about the future of British medicine for a generation.’ Secretary of State for Health Jeremy Hunt praised the report and its ‘buck stops here’ approach. The Daily Mirror even noted that the report was one of the few areas on which the government and the opposition could agree!

‘Future Hospital: caring for medical patients’ places the patient at the centre of healthcare. Organising healthcare delivery around the needs of the patient is at its heart and features extensively in the core principles and 50 recommendations. A series of unequivocal commitments were made to patients, on issues generating considerable patient concern: moving beds in hospital, quality of communication and arrangements to leave hospital. Patients and carers were represented in each of the Commission’s five work streams, led on the recommendations relating to building a culture of compassion and respect, and participated in launch of the report to the media.

The primary focus of the FHC report is on the acute care of medical patients and the views of acute physicians were key to articulating these recommendations. However the report is clear that the solution to current acute pressures on hospitals and specifically in-patient pathways, lie across the whole health and social care system. Care must be delivered in the setting in which the patient’s clinical, care and support needs can best be met and not merely delegated to the acute hospital site. This inevitably means 7 day services in the community as well as in hospital and a consistent new level of “joined up care” with integration, collaboration and information sharing across hospital and all healthcare settings. In keeping with this the report highlights the urgent need to establish alternatives to hospital admission including the extensive use of ambulatory emergency care (AEC), the provision of secondary care services in the community and an expansion of intermediate care rehabilitation services.

Many of the report’s recommendations arose from clinical staff devising innovative solutions to improve the quality of care and ameliorate clinical demand. The report showcased a range of case studies describing service developments and new patterns of care, innovations that would not have been possible without the leadership and sheer determination of physicians and their teams. Dr Jack Hawkins, Acute Physician in Nottingham Queen’s Medical Centre, described how analysis of performance data showing that 50% of acute medical patients were discharged within 15 hours, led to the starting vision for their new AEC service as “everyone is ambulatory until proven otherwise”. The case studies highlight the resources needed to implement service change and the supportive staff relationships and changes to working practices that underpin their success.

The report describes the “acute care hub” as the focus of acute medical services, comprising colocation of the AMU, short stay wards, enhanced care beds and the AEC. Much of this echoes the front door configuration described by the acute medicine task force report in 2007 ‘Acute medical care: The right person, in the right setting, first time’. What the FHC adds are recommendations to co-locate AEC and a clinical co-ordination centre to provide clinicians with real time data on capacity in community-based services (rehabilitation and social services), and link to rapid access specialist clinics or community services to support pathways out of AEC and AMU. Recommendations to structure acute services to maximise continuity of care is a major theme. There should be sufficient capacity in the acute care hub to accommodate admitted patients who do not require a specialist care pathway and are likely to be discharged within 48 hours. This is supported by recommended changes to working practices of consultant led teams where they commit to two or more successive days working in the hub. This allows the consultant led team who first assess the patient in AMU to continue to manage them on the short stay ward through to their discharge – an approach familiar to acute physicians but which may be novel to GIM physicians assigned a single on call day. Striving to deliver continuity by a stable clinical team should also simplify handover, improve training, feedback and the quality and safety of the care delivered.

The commission recommends designating enhanced care (level 1) and high dependency (level 2) beds in the acute care hub to improve the care of acutely ill patients requiring an increased intensity of monitoring and treatment. The RCP acute medicine taskforce made the same recommendation in 2007 but acute trusts have been slow to embed level 2 beds in particular, on AMUs.

In the future hospital every effort should be made to enhance rapid access to specialist pathways that benefit patients, including entry to pathways for acute coronary disease or stroke or the frail elderly direct from the community or emergency department. Here the report is clear that the responsibility for continuity of care rests with the specialty consultant, who should review the patient on the day of admission.

Patient experience should be valued as much as clinical effectiveness. Patients want “joined up care” that is tailored to their acute illness, comorbidities and requirements for social support.

From a patient’s perspective, failures of information sharing between primary and secondary care, or specialist services within the same or neighbouring Trusts, are incomprehensible. The report highlights that this informatics disconnect undermines accurate clinical assessment at the time of presentation with an acute illness, when patients are most vulnerable, and this deficit will impact on patient experience, timely access to specialist staff, patient outcome and resource use.

Robert Francis, in commenting on the report of the Mid Staffordshire public enquiry highlighted that the subject was ‘too important to suffer the same fate as other previous enquiries .. where after initial courtesy of welcome, implementation was slow or non existent’. The RCP shares this urgency and having accepted the recommendations of the FHC as a comprehensive ‘treatment’ for the care of patients in the future hospital, is determined that the FHC report itself will not sit on a shelf, gathering dust.

The RCP is now embarking on a future hospital implementation programme. This programme gathers momentum this month with the appointment of future hospital officers and staff and the immediate priority is to identify partners to set up national development sites. The RCP is seeking enthusiastic clinical teams to investigate changes to a range of hospital and community based medical services in line with the FHC principles and to evaluate the impact on patient care.

Over the next 3 years it is envisaged that the programme will also include research and new approaches to commissioning, workforce deployment, healthcare facility design and integrated working across the health economy. The evaluation of these projects, in relation to the quality and safety of patient care and patient experience, will be crucial and will be shared through the RCP and its partners. In addition, from April the RCP will publish a Future Hospital journal to help share the learning from the implementation programme and welcomes submissions of innovative best practice in acute care.
The challenge now is to convert the goodwill generated by publication of the FHC principles, into an implementation programme nationally, that helps build an effective evidence base to support new ways of providing high quality, safe, patient care. Acute physicians are crucial partners in meeting this challenge.