The Bristol Health Services Plan - SWOT Analysis

The principles underlying the Bristol Health Services Plan are now clear. They have been laid out in a recent document circulated to households in the Avon area. The Plan is clearly sensible and is welcome. However, as yet, we have only seen the outline of the plan: flesh has yet to be put upon the skeleton. The editors, whilst welcoming the Plan in general felt that it might be useful to undertake a critical analysis using the SWOT headings. We aim to be as constructive as possible. What we present here is only a "first shot" and will be subject to modification and change over the next few months. We hope that the debate will now really take off on this website and elsewhere!

The recent document is entitled Building Better Health Services in Bristol, North Somerset and South Gloucestershire. The document starts by pointing out that at present health services are unevenly spread across the area. The document implies that the acute hospitals are not being appropriately used and that some patients could be more appropriately managed elsewhere. This would involve the building of a number of community hospitals and expanded community services. It will be developed in conjunction with Social Services. It is likely that there will be 2 acute hospitals, instead of the present 3, and one of these will be the BRI. The is also a strong move to unify specialist services throughout the city.

1. New community hospitals will undertake the following work:-

1. They will deal with minor injuries.
2. They will provide intermediate care.
3. They will provide some x-ray and diagnostic facilities.
4. They will be the site for some out-patient clinics.

1. There are currently firm plans to build a £25 million community hospital in South Bristol. This will be on a 6-acre site. The location has yet to be decided.
2. Other new community hospitals will include the following:-

1. A hospital in South Gloucestershire.
2. An extension of the services available at Clevedon Hospital.
3. A community health centre for central and East Bristol.
4. A community hospital for North Bristol.
5. An improvement in services available at Thornbury Hospital and in Yate.

Many of our existing hospitals are old and inefficient. They need replacing or renovating. The following specific measures are planned:-

1. Specialist services, and their teams, will need to be brought together.
2. Efforts will be made to ensure the best use of doctors, nurses, and other health workers many of whom work long hours. The hours that they work will need to be reduced.
3. It has been decided that it would not be appropriate to have one single acute hospital for Bristol. The likelihood is that there will be 2 acute hospitals. One will be the BRI and the other will be in North Bristol Southmead, Frenchay, or a new hospital on a green fields site.
4. The BGH will be closed and many of the services will be moved to a new South Bristol community hospital

Clinical services will be moved out of the old BRI building and modernisation of other parts of the BRI will be undertaken.

The following principles are likely to be adopted:-

1. All in-patient services are to be concentrated in the new Childrens Hospital.
2. Local childrens services (out-patients, minor injuries, observation, etc) will be developed along the lines of those that are currently in operation in Weston.
3. Children with serious and immediate needs should attend the Childrens hospital A&E Department.

1. Hospital at home and rapid response teams have been developed. There are also joint teams from Social Services.
2. Home Care Teams will be extended in combination with Social Services so that people can be looked after in their own homes.
3. Some intermediate and convalescent and rehabilitation beds will be established in the community hospitals and in some nursing homes.
4. We should no longer have long-term hospital beds for elderly people who do not need complex medical care.

If there are only 2 main hospitals in the City there would only be 2 main accident and emergency departments. These would be supported by immediate care (minor injury) units near to where people live.

Ways of expanding specialist heart services to meet rising demand are being examined.

From January to April 2004 there will be a series of meetings at which the matters outlined above will be discussed. After this some firm options will be drawn-up taking into account what the public have said.

The Plan is sounds sensible. Because no firm proposals have yet been made it is not possible to undertake a detailed critique. The public is being invited to comment on the proposals (although it is not yet clear what options are being offered). The probable closure of Bristol General Hospital and of the old building at the BRI have been announced and these are to be welcomed.

1. Acute hospitals. Fifteen months ago there was discussion as to whether or not we would have one or 2 new acute hospitals in Bristol. The situation has subsequently changed and there is even the possibility that we shall end up with no new acute hospitals and that any new building would amount to tinkering. Neither of the Acute Trusts has published their plans. This is particularly so in the case of the BRI where the only definite proposal involves the closure of the old building and of the Bristol General. What will replace the old BRI building? Where will any new building occur? What about the other old buildings including the King Edward VII block? What about the road? How can the public comment on the proposals unless information is available? How can anyone judge whether the BRI can be turned into a hospital that is fit for the next 50, and possibly more, years? The decision to retain the BRI as one of the 2 acute hospitals in the city cannot be justified until proper proposals are available and the matter has been fully debated.
2. Community hospitals (CHs). The only definite plan so far published concerns the intention to build a South Bristol hospital comprising 50 beds. Other hospitals may be planned. Again, there are no supporting documents. The precise functions require clarification. Why is the figure of 50 beds chosen? Who will provide the medical staffing? What has happened to the proposal for some "cold" surgery to be undertaken in community hospitals?
3. There is much talk about intermediate-care. What is it? Are there are documents which provide information about the different clinical groups (eg. stroke, post-trauma, frail elderly, etc)-- their numbers and their needs).
4. There is a lack of epidemiological information. There appears to be an absence of both public health and academic involvement. Surely Hugh Ross should be supported by a team which encompasses the relevant expertise.
5. The lack of supporting documents is a major weakness as things stand at present. It is known that many good quality documents have been written, including one on community hospitals. Surely these should be published-bearing in mind that discussions have been proceeding for some years.
6. Information technology. It seems likely that there are major IT implications for the reconfiguration plan. For example, it is likely that the patients will be moved from acute hospitals to community hospitals frequently. It is clear there is potential for records getting mislaid. Will a single patient record be developed? Will this be electronic? What progress is being made?
7. What are the inter-organisational and inter-professional implications of the plan? For instance, it is likely that increased social service provision will be required if less patients are to be in hospital. It may well be that the role of the General Practitioner will change and that he/she may be involved with the running of community hospitals and undertaking the supervision of recently discharged hospital patients. There is likely to be a major increase in the role of nurses in many areas. Consultants will be running clinics in community hospitals.
8. What are the implications for staffing, recruitment, training and education of staff? For instance, medical students will now need to spend more time in community hospitals and working in the community than they have done previously. How will the medical staffing in community hospitals be arranged?
9. What are the research/academic implications of the plan? There appear to be enormous research opportunities. Are these being grasped? If so by whom? Who is undertaking the independent evaluation of the various initiatives and interventions that are apparently being undertaken and are planned? Is anyone collecting together the relevant projects? Where are they summarised?
10. Flexibility. History shows that it is impossible to accurately predict the future. For instance, no one predicted that AIDS would become such a major illness and consume such a substantial proportion of healthcare resources. How will Bristol cope if there is a major epidemic of, say, smallpox or SARS? Other uncertainties exist. How is flexibility to be built into the system?

1. This is the first time that a plan to radically alter the delivery of clinical care in Bristol has emerged. This is a very exciting possibility.
2. In the past ten years Bristol has hosted three of the most serious "scandals" to have hit the NHS during its entire historyone clinical, one pathological and one financial. Many of our trusts have achieved low ratings. We can only go up! Shall we now witness the biggest turnround in performance in the history of the NHS?

1. Money. The original BHSP plan was stalled following the financial difficulties incurred by the North Bristol NHS Trust. Even now, it is totally unclear how this deficit is to be eliminated. It is proving difficult to obtain public approval for cost savings. This is partly because the public do not consider that they "own" the deficit which is widely understood as being due to managerial incompetence.
2. Speed and timing. The BHSP is moving slowly partly due to the delay of a year, imposed by the SHA, following the revelations concerning the financial deficit. A major loss of momentum occurred as a result of this. Bristol is far behind other cities in the UK in formulating its plans and further delay is intolerable. We have already pointed out elsewhere that nationally there are £11 billion worth of building projects in the pipeline comprising more than 100 projects. PFI funding is being sought for them. Bristol isnt even in the queue. This leads to the apocalyptic possibility that much of the BHSP will be fall when the next national financial crisis occurs and funding for major public health projects is no longer available. It seems therefore that speed is of the essence.
3. New initiatives and directives. The current plans are being discussed at a time of frequent governmental directives. These include the recent emphasis on consumer choice, the establishment of Foundation Trusts/hospitals and the likely formation of Childrens Trusts. Hopefully, these, and other, developments will not alter the basic thrust of the BHSP although this is not entirely clear at present.
4. Attitudes of the public and staff. If the public are to be "won over", it is essential that they have confidence in the abilities and straightforwardness of the planners. The planners need to be truthful in what they say to the public. It should not be assumed that people are incapable of grasping the issues. The perception that "it will never happen in Bristol" must be countered. Enthusiasm must somehow be generated and kept alive. The medical profession occupies a pivotal role here.

I have attempted to outline some of the points that need to be considered. Inevitably, the sections dealing with weaknesses and threats are longer than those dealing with strengths and opportunities. Some of the matters mentioned are not, strictly speaking, weaknesses. They might be more appropriately classified as matters that require elaboration.

This is only a first attempt at a SWOT-type analysis and is intended to stimulate debate. The analysis will be updated from time to time over the next few months as and when comments and further information are received. We repeat our general support for the concepts involved. It is hoped that this document will provide a useful contribution for those concerned with moving the Plan forward.

RLH

Joint editor