I work in the NHS, where the principle that healthcare should be commissioned in accordance with local need, in order to make most effective use of scant resources, is well-established. I have been wondering if there are any parallels in the NHS with current free schools policy. The post which follows is the result of my musings:
Imagine a rural area of roughly 600 square miles, where the population of around 270,000 is divided between four market towns and a large number of villages (some of which are fairly large and provide facilities for smaller surrounding villages). This area is currently served by a district general hospital known as St Michael’s, based in the largest of the market towns.
The population is ageing (by 2021 over 65s will account for a quarter of the population), and the numbers of school-aged children are decreasing. It is a fairly affluent area, with house prices above national average, and although unemployment itself is low, the average wage is less than nationally. Larger towns are within 30-45 minutes drive. However, in common with many rural areas, public transport provision within the area and to the surrounding region is poor.
Health and wellbeing are generally good in the area, though as would be expected with an ageing population, there is a relatively high incidence of heart disease and falls (often causing broken hips in the elderly). Public satisfaction with services is generally good, though with concerns about access to services (patient transport in particular), and response times from emergency services. St Michael’s itself is looked on favourably by most people in the area. As part of NHS developments, more outpatient care is now provided in community clinics.
The area is not known for innovation in public services. However in recent years patients in one area (around the village of Abbotsford) have leapt at the opportunity to become more involved in planning healthcare. They recently seized a Department of Health funding opportunity only available for building new hospitals (it could not be used to expand existing facilities), and proposed a new small hospital for Abbotsford. It was to focus principally on delivering elective care in orthopaedics and ophthalmology (hip and cataract operations, for example), as these are areas of high demand by the elderly.
The proposal appeared on first glance to have a number of positives: Patients living nearby Abbotsford would travel shorter distances, local GPs would have closer ties with the new hospital, and staff would be more familiar to local patients. As a new build, it would have excellent though limited facilities and was considered likely to attract staff.
However, on closer inspection there were a number of disadvantages: As a small hospital providing a specific set of services, it could not provide extensive consultant cover or intensive care beds, so would not be able to provide for patients with complex needs such as those with additional heart disease or poorly-managed diabetes. So, many patients who might have wished to use the new hospital would still need to travel to St Michael’s for treatment. At the same time, St Michael’s would not need to provide as many routine procedures as now, so would reduce its capacity in these disciplines. But as there would also be an increase in the proportion of complex patients requiring a longer stay in hospital to recover from operations, overall waiting times for surgery at St Michael’s were considered likely to increase, for factors completely outside St Michael’s control. In addition, there would be risks to patients whose condition deteriorates whilst at Abbotsford, as they would need to be transferred urgently to Intensive care beds in St Michael’s or hospitals elsewhere in the region (providing beds were available). Lastly, core costs at the Abbotsford [new] hospital would be relatively high as the hospital would be a stand-alone provider, with its own board of directors. So overall, costs of providing orthopaedic and opthamology services across this rural area would increase, because two hospitals would need to provide the basic service instead of one, yet standards or patient experience would not necessarily improve, as the new service would only be suitable for some patients.
The proposal enjoyed significant support from Abbotsford patients. However, given the concerns over the impact on St Michael’s, the potential risks to patients, and the expense, the proposal was judged too risky and poor value for money, and the plan was dropped. Yet in education, the opposite happens when Free Schools are proposed in areas like this. Why?