Chris Ham’s article in last week’s Observer newspaper (“Politicians have ducked hard decisions on the NHS for far too long” Sunday 19 June 2011), and a news story in this week’s BMJ (BMJ 2011;342:d3921), claim that up to 20 hospitals, around 10% of the total in England, may not be financially sustainable. 
 
This is highly probable on the current evidence of what is happening, even in well led hospitals like Leicester. Later in the article Chris Ham extends the issue of sustainability into the second of its three dimensions in healthcare: clinical sustainability. With better IT, more empowered patients, more need for collaboration with other agencies such as social care and primary care, and with good evidence of better specialist care in fewer, higher quality tertiary centres, business as usual is not an option for our traditional district general hospital (DGHs). 

The strategy of well led hospitals needs to look three ways (mainly outside their own walls). Firstly, how it networks into systems of specialist tertiary care not provided within its own walls (and no hospital can or should do it all); secondly, inwardly into its own operations and how all dimensions of quality (safe, effective, patient centred, timely, efficient, equitable, and sustainable) can be assured; and thirdly, how it collaborates with social care, primary care, the third sector, and others, in ways that ensure as much prevention and care, where appropriate, is provided as close to home as possible.  And let’s remember that the best care, wherever it takes place (home, school, workplace), is called prevention.
 
But perhaps the third dimension of sustainability that Chris Ham would have alluded to, if space allowed, would have been environmental sustainability. Not simply because climate change is the biggest strategic health threat we face this century: but because many traditional and historical models of care which are ripe for modernisation happen to be unnecessarily carbon intensive. Climate change affects health, and healthcare affects climate change. Better models of care, which focus on prevention, a holistic approach, and avoiding an over-reliance on high tech care simply to extend quantity of  life rather than promote quality of life, are all more sustainable. It could be a virtuous cycle to better health if we grasp the opportunity, and a vicious circle downwards into unaffordable, unsafe, undesirable, and unsustainable healthcare if we do not. 
 
The convenient truth is that the healthcare sector is blessed with plenty of win-wins for us all to exploit:  financial sustainability, clinical/social sustainability, and environmental sustainability. The vision for traditional hospitals may not be that complicated: small, flexible hospitals that are truly a part of the community, coordinating many local services, providing some, and contributing to a much larger system wide approach to tertiary services (not huge, scary illness factories on the city bypass trying to do everything). 
 
If  hospitals were to become more flexible, higher quality, and an essential part, not only of the local community, but also of a wider health system, then they could avoid the biggest problem of all:  “…due to a simple, structural failing: the more services a hospital provides, the more it is paid.” (“Waste measurements” Jun 17th 2011, The Economist online). Incentives clearly need aligning:  patient, financial, technical, and environmental.
 
We should have faith in the future when enough senior clinicians, managers, and policy-makers understand (and act on) this chronic structural failing, so they can make enough sense of the mantra and embed it into the future of their local healthcare system:  “Every unplanned admission to this hospital is a sign of system failure and financial failure until proved otherwise”

David Pencheon is a UK trained public health doctor and is currently director of the NHS Sustainable Development Unit (England).