By Mike George (Health & Social Care Writer)

We have to be careful, very careful of Covid. Quite apart from the enormous damage wrought by the virus itself, the restrictions created in hospitals as a response could easily become ‘the new norm’ for management of patients.

However, we have an opportunity right now not only to challenge aspects of this ‘new normal’, but also to fight for the truly transformative broad changes that need to be made right across our hospital services if the prevention agenda is going to work.

Yes I’m aware that my terminology reeks of the gobbledegook used to announce never-ending streams of NHS initiatives and reorganisations. But we need to reclaim transformative change for ourselves, after all, we keep being told that this is ‘Our NHS’!

Where to start? One might say ‘not here’. What we currently see in the design of hospital estates and services are the result of a mishmash of political, managerial and clinical decisions taken over decades, and shaped by financial constraints.

Does it really have to be like this?

No, but if we are to achieve transformative change which encompasses the diversity of our growing older population and of medical improvements, we have to pose some deep questions, such as what should our hospitals be doing, and how?

A second basic question must be how to devise meaningful prevention. This can’t just be about stopping people from becoming unwell. It must also be about enabling people to be as healthy and independent as possible.

What should be in our Transformative box of tricks?

What are hospital wards for?

To start with the basics, let’s look at these things in acute hospitals called wards. What should their purpose be? Are they just convenient constructs for management systems? To what extent are they really suited to patient needs?

One is tempted to suppose that one day someone came down from on high and said, ‘I name this hospital wing Acme Ward and it shall contain all manner of people who aren’t well and some of the people who help them. But it’s not for people over 65 no matter what shape they’re in’. So another supreme being said, ‘I name this large room Geriatric Ward 47. Actually it’s only for older people but we’ll say it’s called Rose Ward. It has doctors and some nurses and others who do their best to help but we don’t expect many of them to get a lot better’.

Apologies for being flippant or irreverent, but this illustrates how we can too easily accept that particular wards and their roles are set in stone. Surely, with recognised exceptions such as separate suites to treat very specific conditions and to provide intensive care, all other arrangements are ultimately malleable?

And the current state of affairs usually entails patients having to move to a separate building, usually at a different location, to obtain in-patient help with rehabilitation for example. This makes little sense as it creates an unwarranted distinction between medical services and those aimed at rehabilitation. Instead they need to be brought together as part and parcel of the same goal – ensuring that people have the best care to prevent and manage conditions and help them make a good recovery.

Time to get rid of `geriatric’ wards?

Being older isn’t a disease, unlike ageist attitudes and assumptions. Yes, some conditions are more common among older people but we should focus on providing clinical help irrespective of age.

Moreover, it isn’t only among older people that we see a rise in a number of conditions. Some conditions are increasing in prevalence among younger people. For example, increases in obesity and prevalence of Type 2 diabetes mean that many younger people too are at greater risk of developing a range of long-term conditions.

There are plenty of reasons to get rid of separate wards for older people, too numerous to explore here in detail. Overall, the policy of lumping older people into separate wards is outdated, risks stereotyping, and takes no account of the diversity of people’s capabilities and circumstances.

What about visitors?

I had the misfortune last year of being a long-stay hospital inpatient, and experienced the distressing separation from the outside world created by hospitals’ general bans on visitors. This policy also disrupted normal flows of direct information between medical staff and patients’ relatives. The dehumanising effects were compounded by the distancing and difficulties resulting from trying to hear staff through face masks and visors. Consequently, whilst vital for infection control, there are major downsides for patients and relatives.

A number of hospital trusts have subsequently relaxed the ban on visitors but only to an extent; for example, by restricting visits to one person (not allowing other relatives or friends) and to very limited hours.

None of the effects of these changes for patients – which now risk becoming permanent – has received much attention. There have rightly been public debates about relaxing restrictions on visitors to care homes. Similarly we urgently need a properly informed discussion about lifting restrictions on hospital visitors.

Silos and specialists

We also need to tackle the ‘specialist silo syndrome’. A good Anti-Silo tool is needed to ensure there’s better integration between medical specialists and general consultants to improve decision-making, and to improve communication with patients and relatives.

Putting prevention at the core

Some hospitals are centres of excellence for certain diseases and conditions. However, they and other acute hospitals need to incorporate prevention programmes and activities as an integral part of their systems, not as add-ons.

Services aimed at prevention and rehabilitation are mostly under-resourced and often ancillary to what might be seen as the more important business of medical treatment and `heroic’ medical interventions. Instead, we need to raise their status, resource them properly, and ensure they are completely integrated within core hospital services.

And how about incorporating from the start a real, concrete, set of arrangements to ensure proper patient involvement: no tokenism please.

Stop deconditioning

It should be routine for all hospitals to have as Priority One a ‘don’t decondition patients’ programme with a senior person in charge. We must never allow hospital deconditioning to make patients more ill because of poor nursing care, restricted mobility, inadequate nutrition or hydration, or lack of action over drugs’ side effects.

Sounds obvious but, as I know to my cost, when I left hospital I was malnourished, had acquired anaemia, eczema and dental damage alongside other distressing effects. And my experience was by no means unusual.

In conclusion

It should be obvious but to help us move on from an illness state (unless we’re in real trouble), we need different types of support at different stages and these need to be designed with flexibility in mind. Therefore our hospital services and systems have to be reconfigured to make a better `new normal’. Many will regard such a challenge as simply `not affordable at this time’, or we need to `be realistic’ during these Covid times.

But, to be properly realistic, we have to recognise that our hospitals are failing to meet the health needs of our increasingly older population in many fundamental ways, not only in terms of managing and preventing ill-health but in maximising the chances of good recovery outcomes.

Above all, hospitals can’t necessarily be nice but they can be better!

ILC are running a project: Delivering prevention in an ageing world programme, which seeks to encourage governments across the world to invest in preventative health and tackle inequalities in access to health. Find out more here.