Comment
www.thelancet.com Vol 382 September 14, 2013 925
Roya
l Col
lege
of P
hysic
ians
Offl ine: Clinical leadership improves health outcomesThe Royal College of Physicians of London has had a diffi cult few years. It was accused of a slothful response to the hated 2012 Health and Social Care Act. Its President had to beat off unwelcome opposition in a recent election challenge. And the College has been under pressure following the scandalous events that took place at Mid Staff ordshire NHS Foundation Trust. But that was the past. This week, the College’s Future Hospital Commission, chaired by Michael Rawlins, published its fi nal report. The Commission has produced the most important statement about the future of British medicine for a generation.
*
Although Michael Rawlins began his work in March, 2012, the imprint of Robert Francis’s 2013 report of the Mid Staff ordshire NHS Foundation Trust Public Inquiry is present throughout. The Commission opens with a quote from Francis: “The patient must be the fi rst priority in all of what the NHS does.” There is something clearly wrong in British medicine if this statement has to be made at all. The Commission acknowledges Francis’s conclusion that there is “an apparent lack of compassion among healthcare workers”. It does not fl inch from accepting “profound failings in the standard of basic, essential care”. In response, the Commission off ers a “new” and “radical” vision. It makes a strong and unapologetic case for hospitals “at the hub of a new system of care”. And it unites clinical medicine with public health: “The hospital and its staff also have an important role in promoting healthy behaviours and avoiding health harms.” Here are the Commission’s ten big ideas.
1 Hospitals must off er “seven-day care, delivered where patients need it”.
2 It’s time to build a new movement for generalism, not specialism—”generalists are the undervalued cham-pions of the acute hospital service”.
3 Hospitals need “a single unifi ed Medical Division...[with] clinical, managerial, and budgetary respon-sibility for all inpatient beds”.
4 A Chief of Medicine will lead the Division and will be responsible for monitoring performance, safety, and quality improvement.
5 A Chief Resident, a “designated junior doctor”, will assist and report to the Chief of Medicine, planning service delivery and redesign with a special emphasis on junior medical staff .
6 Each hospital will have a Director of Medical Education to continuously improve training.
Gett
y Im
ages
Corb
isRo
yal C
olle
ge o
f Phy
sicia
nsGe
tty
Imag
es
7 A new Director of Clinical Information will ensure that information, including patient-reported outcome mea-sures, will be used to support care and measure success.
8 Technology—email, texts, and video conferencing—will be used to communicate between patient and doctor, support self-management for those with long-term conditions, and conduct virtual clinics and ward rounds.
9 An Executive Director for Research should be respon-sible for promoting research within each hospital; all NHS Trust Boards should receive regular reports on research activity.
10 Finally, the hospital must tear down its walls: “the concept of the hospital needs to change radically”, integrating the management of chronic disease with general practice in the community.
*There are gaps in this vision. First, services for children, women, and those requiring surgical expertise are excluded from the Commission’s report. Although these omissions are understandable in a Commission established by physicians concerned mostly with adult medicine, there now needs to be immediate outreach to these missing spheres of hospital care. Second, it is disappointing that almost nothing is said about the importance of health professionals who work alongside physicians—notably nurses, but also pharmacists and other colleagues without whom the hospital could not func tion. As important as physicians might be, the Commission risks sending out a signal that it cares little for the rest of the health-care team. If the Commission’s vision is to be realised, common cause must be made with all those who make the hospital “the hub” of the health system. Finally, no mechanism is proposed to evaluate these big ideas, to ensure they deliver what is promised—”collaborative, coordinated, and patient-centred care”. If the Commission’s report is to make a diff erence, the College must have a robust mechanism to ensure the Com mission’s recommendations are fully implemented. Despite these caveats, the Commission’s work is a strikingly important commitment to learn from the mis takes of the past, to secure a safer and more eff ec-tive health system for the future, and to meet the expec-tations of a public whose confi dence in the NHS has been sorely tried in recent years. The College deserves praise for making this opportunity possible. Now make it happen.
Richard [email protected]
