pH7 Magazine - Carry On Doctor

The focus needs to be on the DGH. The present concept of the DGH was invented in the days when Enoch Powell was rationalising a relatively young health service by moving it out of the many small hospitals that it had absorbed. The idea was to assemble the major disciplines of secondary care under one roof. In doing so, Powell has given the NHS a huge advantage over Continental and North American services, which still depend on small institutions with many specialist doctors practising from independent offices. Compared with these, there is no such thing as a small district general hospital. However, the smallest DGHs have borne the brunt of years of parsimony in the NHS, and have been badly affected by decisions as to where resources should be denied.

When the economics are studied, it emerges that the optimum size of a DGH is around 600 beds. Up to this point, economies of scale apply which emphasises the NHS’s advantage over other systems. Economies of scale do not go on for ever: as my school economics teacher used to put it, double-decker buses are more efficient than single-deckers, but triple-deckers would not fit under bridges and would fall over around corners. Over 600 beds, inefficiencies set in and this is why the temptation to enlarge academic hospitals should be resisted.

Developing and investing in services in DGHs keeps the NHS local. Powell’s policy of having many disciplines under one roof fits perfectly with modern perceptions that healthcare professionals work best in multidisciplinary teams, especially in the cancer field.

Centralising services such as radiotherapy, another part of 1960s policy, was a sensible approach to maximise the use of a major capital asset, in this example the radiotherapy equipment. However, the result was the isolation of disciplines of cancer treatment from the DGH in a way that does not happen in other countries. The present solution to this problem involves the conversion of large amounts of fuel into greenhouse gases by both doctors’ and patients’ vehicles, when this could be avoided.

It is especially important to allow the culture of co-operation between DGH consultants and local GPs to develop both socially and professionally. Historically this benefited patients greatly and had enormous educational value, because lines of communication were well established and well-used. Increasing workloads without increasing resources have impeded these relationships and it would be of immense value to reverse this.

One of the ways in which diseconomies of scale are manifest is in the recruitment and retention of staff. This makes an important difference to communication and the continuity of care, which is coming increasingly under pressure, especially from the European Working Time Directive. Our DGH is good enough at recruiting secretaries for us to inform a GP about a consultation within a week, but incoming correspondence from the Network Cancer Centre takes at least three weeks and often more. The person who has taken a career break is more likely to return to a healthcare profession if it is possible to practise it locally.

Independent sector treatment centres can indeed increase healthcare capacity, but they are designed for a rapid turnaround of straightforward conditions managed at predictable cost. They cannot handle the diagnostic dilemmas that are so common in routine practice. They cannot provide the multidisciplinary environment that is especially important in dealing with patients with other concurrent illnesses.

DGHs have changed over the years. Generalist services have differentiated into specialisms and their numbers have increased. To meet the modern needs of patients more professionals need to be recruited. The best institution in which to locate this expanded workforce is the district general hospital.

The focus needs to be on the DGH. The present concept of the DGH was invented in the days when Enoch Powell was rationalising a relatively young health service by moving it out of the many small hospitals that it had absorbed. The idea was to assemble the major disciplines of secondary care under one roof. In doing so, Powell has given the NHS a huge advantage over Continental and North American services, which still depend on small institutions with many specialist doctors practising from independent offices. Compared with these, there is no such thing as a small district general hospital. However, the smallest DGHs have borne the brunt of years of parsimony in the NHS, and have been badly affected by decisions as to where resources should be denied.

When the economics are studied, it emerges that the optimum size of a DGH is around 600 beds. Up to this point, economies of scale apply which emphasises the NHS’s advantage over other systems. Economies of scale do not go on for ever: as my school economics teacher used to put it, double-decker buses are more efficient than single-deckers, but triple-deckers would not fit under bridges and would fall over around corners. Over 600 beds, inefficiencies set in and this is why the temptation to enlarge academic hospitals should be resisted.

Developing and investing in services in DGHs keeps the NHS local. Powell’s policy of having many disciplines under one roof fits perfectly with modern perceptions that healthcare professionals work best in multidisciplinary teams, especially in the cancer field.

Centralising services such as radiotherapy, another part of 1960s policy, was a sensible approach to maximise the use of a major capital asset, in this example the radiotherapy equipment. However, the result was the isolation of disciplines of cancer treatment from the DGH in a way that does not happen in other countries. The present solution to this problem involves the conversion of large amounts of fuel into greenhouse gases by both doctors’ and patients’ vehicles, when this could be avoided.

It is especially important to allow the culture of co-operation between DGH consultants and local GPs to develop both socially and professionally. Historically this benefited patients greatly and had enormous educational value, because lines of communication were well established and well-used. Increasing workloads without increasing resources have impeded these relationships and it would be of immense value to reverse this.

One of the ways in which diseconomies of scale are manifest is in the recruitment and retention of staff. This makes an important difference to communication and the continuity of care, which is coming increasingly under pressure, especially from the European Working Time Directive. Our DGH is good enough at recruiting secretaries for us to inform a GP about a consultation within a week, but incoming correspondence from the Network Cancer Centre takes at least three weeks and often more. The person who has taken a career break is more likely to return to a healthcare profession if it is possible to practise it locally.

Independent sector treatment centres can indeed increase healthcare capacity, but they are designed for a rapid turnaround of straightforward conditions managed at predictable cost. They cannot handle the diagnostic dilemmas that are so common in routine practice. They cannot provide the multidisciplinary environment that is especially important in dealing with patients with other concurrent illnesses.

DGHs have changed over the years. Generalist services have differentiated into specialisms and their numbers have increased. To meet the modern needs of patients more professionals need to be recruited. The best institution in which to locate this expanded workforce is the district general hospital.

There is a naïve assumption that, because a designated central service exists, everyone who can benefit is offered it. The introduction of mandatory discussion of patients in multidisciplinary team meetings has exposed some of the deficiencies, but the lack of capacity, especially the lack of personnel, means that patients may only be considered around the time of the diagnosis. This should maximise cure rates, but modern treatments mean that even when a cure is not achieved, more cancers are becoming chronic diseases requiring long-term specialist attention.

The system whereby the meeting is the main point of contact between oncologist and DGH is inadequate. Recently this was revealed in the variation in the use of new anticancer drugs in the UK. Management of chronic diseases by local specialists is an ideal function for the DGH.