Recent and Emerging Trends. The Future of Acute Hospitals - Challenges and Risks

The long-term historical trend toward a smaller number of acute hospital beds and a reduced reliance on acute inpatient care has already been noted. It has perhaps been most pronounced in the United States, but is clearly visible in all high-income and many middle-income countries.

This trend has been less clear in developing countries, due in part to more limited data availability, and also to the very low baseline of health service provi­sion in more countries - services that are inadequate to meet current needs would hardly be expected to shrink. In richer countries this trend has been driven by multiple factors - better treatments and outcomes, reduced length of stay, significant substitution of acute hospital stays with stays in nursing homes, rapid growth in the ability to offer interventions on an ambulatory care basis, and explicit economic incentives (see Hensher et al., 1999b, for a fuller discussion).

A parallel trend visible more recently has been a ten­dency to concentrate more complex interventions (par­ticularly, but not exclusively, specialized surgery) onto a reduced number of centers. This trend has reflected growing evidence that surgical and other outcomes are related to the volume of specific procedures undertaken by an individual practitioner.

For many procedures, there is now evidence that outcomes are poor when practi­tioners undertake only small volumes; perhaps most far- reaching in its implications has been evidence indicating that outcomes are poorer in trauma surgery outside specialized major trauma centers. As a result, many health systems have attempted (via differing mechanisms) to ensure that less common procedures are concentrated into specialist centers.

When combined with the parallel shift of simpler activity out of hospital and into ambula­tory care, this raises the prospect of a subset of hospitals (primarily smaller general hospitals, without specialist centers of expertise) being left with too small a core of inpatient services to remain economically viable.

Were such hospitals to close, then local communities may face significant reductions in their ability to access basic acute care - a trade-off sometimes not explicitly addressed in discussions of the benefits of service concentration of specialized procedures.

The Future of Acute Hospitals - Challenges and Risks. A growing challenge for acute hospitals has been the steady rise in the incidence of drug-resistant health-care-acquired infections (HCAIs), such as methicillin-resistant Staphylo­coccus aureus (MRSA) and Clostridium difficile. HCAIs have, in many developed countries, become endemic in acute care hospitals, with around 9% of hospital patients in England infected with an HCAI at any one time (Public Accounts Committee, 2005).

HCAIs lead directly to the death of some patients; undermine care outcomes for many more; lead to increased resource utilization and costs in the care of infected patients; and undermine patient and public confidence in hospitals and health care more generally.

Pharmaceutical solutions to HCAIs seem not to be forthcoming; HCAIs are therefore likely to continue to require greater attention to infection control, effective case finding, using ambulatory care to avoid admission to hospital in the first place, and even changes to the physical design of hospitals if they are to be controlled effectively.

In the worst case, a failure to deal effectively with HCAIs could turn the clock back signifi­cantly on acute hospital care - the long downward trend in hospital stays could be reversed, and the public may cease to view hospitals as places of safety - reverting to their pre­twentieth-century status as risky environments in which only those who cannot afford other forms of care would willingly enter.

It is also possible that recent patterns of acute hospital care may be challenged in adapting to a low-carbon future. Service models that are reliant on long or frequent journeys for either patients or staff might need to be reconsidered if transportation costs start to rise signif­icantly, due either to carbon taxes or increasing fuel scarcity.

There is little doubt that - barring truly extraordinary scientific breakthroughs - the acute hospital will still be with us in a hundred years’ time. Even if its physical form has changed, and the treatments provided within its walls have changed completely from those we know today, the future hospital as a social institution would still be clearly recognizable to us.

The challenge for health systems is to seek a continuous rebalancing of care provision and loca­tion to reflect changing technologies, capabilities, and relative costs. The designers of acute hospital systems for the future - whether in rich or poor countries - will need to strive constantly to ensure that hospitals provide only that appropriately specialized acute care that cannot be more cost effectively delivered in other settings - but that they also support primary health care integrally through the wider distribution of information, expertise, and skills.