|Home | About | Journals | Submit | Contact Us | Français|
This week sees the publication of Healthcare for London: A Framework for Action, a review of London's health service by Ara Darzi, chairman of surgery at Imperial College London and now a junior health minister (see News doi: 10.1136/bmj.39273.467697.DB). NHS London, the capital's strategic health authority, commissioned Professor Darzi to set out a vision for a world class health service for London.
How refreshing it is to read a policy document that focuses on real health problems and makes practical suggestions about how to solve them. Not for Professor Darzi a theoretical exposition of system reform or a set of proposals for organisational change that seem remote from the delivery of health care at the coalface; instead he gives us a vision of future health care in London that simply makes sense. His work, too, heralds the welcome return of service planning—much derided by governments over the past 20 years but necessary even where providers operate in a competitive market environment, giving clear signals of long term intent to attract potential investors.
Many of London's healthcare problems have been well known for generations. They include gross health inequalities, inadequate primary care, and an outdated pattern of secondary and tertiary hospital provision. What Professor Darzi brings to this afresh is an evidence base that will engage clinicians in the need for change. His work also brings into sharp relief one of the hidden scandals of health care in the United Kingdom: our collective failure to treat stroke effectively.
Stroke remains the third biggest cause of death in England. In people aged under 75, mortality from stroke fell by 44% in men and by 43% in women between 1993 and 2005 in England. But this improvement must be seen in the light of international trends in stroke mortality, which show the UK with higher mortality than similar countries (www.health.org.uk/qquip). Similarly, mortality from cerebrovascular disease in the UK has been falling steadily, yet again the UK has a high mortality in comparison with similar countries.
The Royal College of Physicians' national clinical guidelines for stroke recommend that thrombolytic treatment be given within three hours of onset of symptoms after an ischaemic stroke. Yet the college's sentinel stroke audit shows that, in 2006, only 12% of hospitals had arrangements with local ambulance services for emergency transfer to hospital for acute stroke, over and above the regular system, and that only 18% of hospitals offered a thrombolysis service (www.rcplondon.ac.uk/pubs/books/strokeaudit/index.asp). Notably, over 12 months no patients underwent thrombolysis in 10 of the 40 sites offering the treatment, and only 218 patients in total (0.2%) underwent it. This is a tiny proportion of the patients who could potentially benefit.
The Darzi plan has the potential to transform London's stroke services and place them among the best in the world. Where London leads the rest of England might follow. But will these and the other radical changes he proposes ever be implemented? The history of reports into London's flawed health services is not a good one. Neither the 1992 Tomlinson report nor the Turnberg one of 1998 were ever fully carried out.
In the past, institutional vested interest—dressed up as protecting local services for local people—has prevented the emergence of a rational pattern of secondary and tertiary hospital services. Perhaps now it has been realised that to compete effectively in the global economy of medical research there really is only scope for two academic health science centres and that collaboration between the players to create such institutions is the only means of survival. Perhaps, with the Department of Health's current policy to make NHS finances more transparent, and the emergence of foundation trusts that need to be fleet of foot in adapting to commissioners' new requirements to protect their income, there is no longer anywhere for institutions to hide while mounting their campaigns to resist change.
The reaction of the medical profession will be important. When the new health secretary, Alan Johnson, spoke recently in the Health Service Journal about the need to re-engage clinicians (www.hsj.co.uk, 5 Jul, “Johnson and Darzi lead Brown's campaign to woo back voters”), many in the profession will have interpreted this as a willingness of the government to slow the pace of change. Many health professionals, not least those in general practice, will view Professor Darzi's recommendations as being far from this, as the implications for primary care are potentially the most radical aspect of his plan. They spell the end of general practice as we know it. Not only would single handed practitioners disappear, but GPs in group practices would have to collaborate in the delivery of the comprehensive multidisciplinary care envisaged for the “polyclinic.” This potentially heralds the entry of new players into primary care, be they foundation trusts or commercial enterprises.
Just one word of warning. With the Darzi report's focus being inevitably on the overall pattern of services needed in London, the danger is that the service may spend a great deal of energy putting old wine into new bottles. As care is transferred into new settings it must become safer and more reliable for patients. This process will require detailed redesign, different delineation of roles, and a cultural shift. If we provide clinical leaders with the training, capacity, and authority to lead this process we stand a fair chance of carrying the public with us.
London's healthcare problems have been well known for generations
Competing interests: ST is a non-executive director of Monitor, the independent regulator for NHS foundation trusts.