I have often wondered, during all the discussion of whether one’s local hospital should be shut down, whether hospitals are safe places for patients to be in. Let me rephrase that. Are they safer places to be in, rather than your own home?

I tend to think, surely, that clinicians can’t think hospitals are particularly safe places to be in, otherwise they wouldn’t be in such a rush to have them ‘flow’ in and out? But there are of course economic considerations, for example the cost of a hospital bed being more than the cost of a bed at the Ritz, and so on.

The Royal Colleges of Physicians have warned on numerous occasions about the service being understaffed and overstretched, and the Royal College of Nursing and others have for a long time, famously, been campaigning for safe staffing.

Patient safety supposedly is King, but the problems appear not to go away. The issues with patient safety continue to linger like a bad smell. Take, for example, the Mid Staffs scandal and the current issues with the NMC and maternity care deaths.

In recent years, the focus seems to have been on structures, processes and operations, rather than people and needs. Whilst the slogan ‘person-centred integrated care’ is everywhere, it continues to be the case, perhaps, that people have to be built round services rather than services fitting round people.

For many outpatients, a trip to outpatient’s can be an unpleasant experience, especially if you’re travelling a long distance by car and then have to negotiate an astronomic car-parking fee at the end of it. For patients who are literally bed-bound, and who can otherwise travel only with a carer and a wheelchair, a trip to hospital can be a monumental task.

Hospitals can be the very worst places for certain groups of patients, for example patients who are frail, living with dementia and experiencing delirium. A sudden change of environment from home to hospital can be catastrophic for the delirium, and so can a plethora of other issues in hospital (such as bed rails, lack of communication, inappropriate sedation, inappropriate extensive de-prescribing, etc.)

Whilst hashtag campaigns can be somewhat hyperbolic, it is true that the #endPJParalysis campaign has drawn attention to the issue of patients languishing in beds for weeks such that when they are finally discharged they can no longer walk and have lost their ability to perform certain activities of daily living.

And the medical issues resulting from hospitals, including hospital-acquired infection, pressure sores, DVTs, are well known.

An issue with integration and making a case for change is that, particularly following the introduction of the ubiquitously-despised Health and Social Care Act (2012) from Andrew Lansley, the natural reaction has been to assume that everything is essentially a cost-cutting exercise on the road to privatisation.

But the case of artificially dividing health and social care is no longer tenable. Ahead of talk on processes and structures, such as pooled budgets and organisational structure, there is a basic issue that people for example with long term conditions such as frailty and dementia can have substantial care needs, such as personal care or washing and dressing.

It has long been claimed that mortality is unaffected in palliative care, but anecdotal evidence appears to be that certain healthier patients, despite living with life-limiting terminal conditions, can live longer if in better health.

It could be that one’s own home is a safer place to be?

With initiatives such as ‘NHS Ageing Well’, if we are to take seriously living independently and reablement, we do need to make sure physical health, social health and mental health are on the same footing. This has for ages has been known as ‘making parity a reality’.

In a report from the King’s Fund on #socialcareoptions this morning, it’s been argued that we’ve reached a fork in the road between the universal NHS and means-tested social care system.

I believe strongly that the divide between health and social care is utterly unproductive, and that we cannot have a system which unfairly discriminates against service users to their financial detriment according to what a condition is.

It could be that there is a genuine issue with safety in hospitals (a “push” factor). And that people’s quality of life is genuinely enhanced with independence, provided that this does not lead to isolation (a “pull factor”).

But I think, personally, the idea of hospitals being the “ultimate institution” is long dead. I’ve never met a single patient who says he’s really ‘enjoyed’ being in hospital, and further might exacerbate the sense of ‘otherness’ people with certain conditions might feel.

The NHS is a movement, rather than, merely, a collection of buildings (like hospices are a movement). With the growth of ‘hospitals at home’, there is now a tendency for promoting health, not just fixing illness, to need to take place at the right place, right time, and right way.

 

 

@dr_shibley

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4 Comments

  1. Eric Alan Leach says:

    Are homes always safe places to be in?

    The answer is no if you are seriously ill or critically injured. Perhaps the word ‘safe’ might be replaced by the word ‘appropriate’.

    I’m not good at maths but 237 Acute/District General Hospitals for 59 million residents across 50,000 square miles is probably too few. Instead of planning to get rid of some of these hospitals we should be building more of them.

    The 2009 McKinsey & Co dogma that 40% of patients should not be in Acute hospital beds can only have any veracity at all if mental health beds and beds for the elderly are in plentiful supplier outside Acute hospitals. Over the last nine years this Out of Hospital nirvana doesn’t appear to have been achieved anywhere in England.

  2. powerful comment – thanks

  3. B says:

    Dt Shibley hides his intentions.
    Does he want Social care to be more like the NHS or the NHS to be more like social care?
    If the former he will be told we cannot afford it and if the latter then we have a means tested NHS and no longe a pretence of a comprehensive service.
    say what you mean

  4. Actually – you’re right. I never said that explicitly. I want the whole lot to be universal, free at the point of need/use and comprehensive, paid out of general taxation. The very last thing I want is any payment system, co-payments or mean-tested etc., from the NHS. Good point ++

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