David Payne: Do we still need hospitals (and hospital beds)?

IMG_0495During a conference coffee break last week two physiotherapists pushed a hospital bed through the networking area, along with a wheelie bin overflowing with “redundant” bed-related paraphernalia—monitors, clipboards, etc.

The hospital where Shanna Bloemen and Yvonne Geurts work plans to remove beds during the day to encourage patients to get active and get out of the wards. Implementation is due to begin in the department of cardiothoracic surgery and will be extended to others over time.

Ban Bedcentricity, as the campaign at Radboud University Medical Center in Nijmegen, the Netherlands, is called, says healthcare is currently too “bed centred.” This makes patients easier to find and hospital wards easier to arrange, but beds encourage physical inactivity.

IMG_0465

Patients spend on average 80% of their time in their beds, they say, and most have no medical reason to stay in bed. Also, the physical inactivity it encourages can result in loss of muscle strength, neuromuscular control, and physical endurance.

But why stop at beds? What about hospitals? Do we even still need them? And if we do, should they even still be called hospitals?

Yesterday a blog post by Céline Miani and Eleanor Winpenny from RAND Europe and Cambridge University, respectively, outlined the push from secondary care to the community. They write about a RAND review, undertaken jointly with Cambridge University, which outlined five key areas for shifting care, but their post did not discuss how hospital architecture will change as hospitals adapt to their new “bed-decentralised” future.

Tony Young, a urological surgeon and NHS England’s national clinical director for innovation, used a film still of a burning hospital building to raise the question when he addressed a conference about future healthcare in London last month.

“Do we need to blow up all our hospitals and start again?” he asked. “Would we design the system we currently have if we were starting now?

“The challenges we face now is not just a problem in the NHS or the UK. It’s a global challenge. We designed a system in the NHS nearly 70 years ago that dealt with acute conditions, largely based around hospitals.”

“Modern hospital” design predates the dawn of the NHS in the late 1940s. The building design championed by Florence Nightingale based on her experience of nursing soldiers wounded in the Crimean war went largely unchanged for almost 150 years.

Nightingale wards helped facilitate observation and foster good hygiene practices, but if observation takes place in the community with specialist services accessed digitally and remotely, doesn’t the hospital become more like a university campus, where the growth in online learning now means students rarely, if ever, need to set foot inside a classroom?

At the Our Future Health conference in Nijmegen, architect Daniël van den Berg described how Radboud surgeon Harry van Goor and the hospital’s real estate director had challenged him to consider the hospital’s future needs and how a five year building project can anticipate technological advancement.

He added: “The most probable outcome is that healthcare moves towards the home. Would it not be great if hospital environments were there only for necessity, for a very short period of time?

“Harry’s question to architects was: ‘If we look at patients’ needs do we really want to build hospital environments? We need to reinvent our profession as architects, using more intelligent technology to reduce the size of these facilities.”

If the physical environment of the hospital is changing, why not its name too? Princess Laurentian van Oranje, sister-in-law to King Willem-Alexander, told the conference how her work with Dutch Children’s Councils had convinced her that the Dutch word for hospital—Ziekenhuis, literally meaning “sick home”—was anomalous.

“They asked: ‘Why do you call it a sick house?’ It’s a place where you try to get people better.”

David Payne2David Payne is digital editor, The BMJ

The Our Future Health conference was organised by Lucien Engelen, director of the medical faculty’s REShape Innovation Center and leader of its Patients Included kitemark. The BMJ received one in June 2014 for its patient partnership initiative.

(Visited 235 times, 1 visits today)
  • Bill Cayley

    It is indeed ironic that the hospital, which began as a place of caring and healing, has now become know primarily as a place of depersonalization, techonology, checklists, and immobility. There are, of course, some facets of medical care that need a high-tech home (not ready to do heart surgery in our small rural clinic just yet!) but on the whole, the more we can focus on CARING, HEALING, and RECOVERY, the better!

  • Nick Mann

    Before further reduction to the 55% of hospital beds already cut since 1987 and the proposed complete annihilation of England’s existing health service, should we not be wary of such grand claims for remote monitoring as a viable, desirable or safe means to replace on-site medical teams and support?
    The evidence to date for remote monitoring is not supportive. The very idea that we can have an equal or better quality health service with more cuts, no beds and IT backfill is either laughable or dangerous – a Trumpesque lack of merit or scrutiny.
    And what drives this? The argument that the ‘NHS is unsustainable because of the ageing population, immigrants etc’ has been robustly challenged by King’s Fund analyses. The NHS is where it is because of political choices over funding, as our comparison to equivalent countries very clearly demonstrates.

  • Dr Dave

    The current model of hospitals reminds me of my days as a private pilot. Flying a plane is basically no different then hospital care. It is 95% shear outright boredom combined with 5% outright terror. When things go well the plane as well as the hospital are nothing more then mundane entities with huge expenses and little results. When the 5% takes over then we wish we had better equipment more staff unlimited funds and the finest communication skills at our disposal.
    In reality 95% of hospital beds are nothing more then observation beds used no differently then hotel beds. The same observation/recuperation beds could be at one’s home or other. After 30+ years of surgery I find that what used to be a 6 or 7 day post operative convalescent time is now done either as an outpatient or cut in half not based on some requirement from an insurance company but simply based on no more need to be hand held and watched by very expensive staff.
    More people get sick in hospitals from nosocomial infections then are cured in hospitals with infections brought in from outside. All in all hospitals in the future will be strictly for the VERY critical post operative and required observational patients and the rest will be monitored quite fine at their place of residence with sophisticated monitoring equipment and equally sophisticated staff to insure both safety as well as efficiency. We aren’t there YET but to suggest we aren’t very close is equally closing one’s eyes to reality. Society no longer needs to retain old technology and philosophy simply because… Time we adjust to the times even if the initial band aid pull off is going to be really really painful. Dr D

  • Nick Mann

    Focus on caring, healing and recovery is what I do, effectively and efficiently, every day. Using knowledge,skill, experience and human contact. Remote monitoring does NONE of these things. This pejorative view of hospitals comes from the same stall as that which deems the NHS unsustainable. How many hospital beds does a country need? How do economies of scale of a hospital compare with cost of case-based care at home? And what of managing investigation, IV maintenance, equipment, transport etc? Not sure I’ve seen any credible evidence of strategic workforce or infrastructure planning, or figures or costings to support these aspirations.

  • Nick Mann

    At what point would you be prepared to board a pilotless plane? Where is the evidence and detail to support any of these ‘integrated care’ proposals? How will you evaluate the increase in unattended complications and mortality resulting from hospital closure and failure to access timely intervention? Despite use of technology, hospital care in the community will require more staff, not fewer. Hospitals permit economies of scale. Similar to the ‘7-day NHS’, this is uncosted, unplanned and unfunded. At best it’s wishful thinking, at worst it’s dangerous – flying completely blind into uncharted waters, in an already critically underfunded health system.

  • trio corporation

    Nice blog with lots of information.

  • Ed Walker

    Having worked in hospitals for over 30 years, they’re a BAD idea. I mean, if you’re ill, that last place you need to be is in a place surrounded by other ill people.
    The idea of gathering the sick in one place was originally to protect others from disease. Then the idea of ‘hospitality’ came about, but more for travellers than for the sick. Then doctors were invented, who needed sick people to use as teaching subjects, and it was convenient to have them under one roof. Then technology turned up, and it was convenient to have really sick people nearby the gadgets that had been invented to try and cure them.
    But none of that gets us far from my first premise, that if you’re ill, I mean really ill, you don’t want to be in a building full of other really ill people.

  • Nick Mann

    I’m not sure what aspirational reality you inhabit, but I assume your irrational fear of “other really ill people” is based on the paranoid notion that you “might catch something from them”. In my reality, the overwhelming majority of nosocomial infections occur after surgery, which will – unless we resort to faith healing – continue to be carried out in a hospital environment. Or perhaps you would find all those ill people “a bit depressing”. I feel rather differently, and very much value the personal care, support, expertise and shared experience which have been the hallmarks of my experiences as both patient and doctor in NHS hospitals.