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Plans to focus hospital services and build polyclinics will have to overcome inertia and rivalries
Last week saw the launch of Healthcare for London: A Framework for Action, the findings of a review led by Sir Ara Darzi, chair of surgery at Imperial College.1 The review was commissioned by NHS London in 2006, but its contents have assumed a greater significance with the recent appointment of Sir Ara as a junior minister, charged with a wider review of the health service throughout England.2 The terms of reference for that review make clear the government's determination “to ensure that the future of the NHS is clinically led” and that vision is pre-eminent in his London report.
The review has been based largely on the views of clinicians, concentrated into six working groups of “clinical innovators” drawn from a range of organisations, including the King's Fund, to look at clinical pathways. They looked at maternity and newborn care, services for staying healthy, acute care, planned care, long term conditions, and end of life care. Mental health was considered by a seventh group, and the overall analysis also included a public opinion poll and two “deliberative” events involving members of the public.
The resulting report makes a cogent case for change in London. It describes a highly mobile, highly diverse population with stark health inequalities. Londoners are less satisfied than the rest of the English population with the health services they receive, and their needs are clearly not being met adequately. Furthermore, the review finds that the current configuration of services is not fit for purpose. It argues for more care at home and in the community, citing, for example, studies that show better outcomes for patients with chronic obstructive pulmonary disease and heart failure when they are offered targeted community services. It also points to powerful evidence that more specialisation in bigger hospitals can save lives, notably in dedicated stroke units, and calls for the urgent reconfiguration of services for stroke and trauma. In addition it calls for rapid work to improve the skills of the London Ambulance Service.
Improved services should be focused on individual needs and choices; they should be local where possible and central where necessary; they should be integrated (bridging the gap between primary and secondary care); they should encourage prevention; and they should focus on health inequalities and diversity. Perhaps inevitably, recommendations on the best location of services—including fewer, more specialist hospitals and, in the next two years, “between five and ten polyclinics” which would bring together general practices with community, diagnostic, and urgent care services—have prompted particularly widespread coverage and debate.
A great deal in this review is to be welcomed: its emphasis on outcomes, the experience of patients, and inequalities, as well as its search for a solid evidence base to drive decisions about health care services. The evidence base is, however, incomplete in some areas (how much evidence is there that polyclinics are the answer for every locality?) or absent in others (there are huge gaps in our knowledge of which interventions deliver best outcomes for such an ethnically diverse population). Nevertheless, this emphasis on evidence should help local NHS commissioners and providers construct and communicate a more robust case for change to a sceptical public.
Finally, the review says little about how the levers of system reform in the NHS can help to realise this vision. Yet it will be crucial to understand how the multiple and sometimes conflicting incentives that have already been built into the system will help or hinder the road to implementation. Payment by results (the mechanism to pay NHS providers a fixed price for each individual case treated), for example, has created powerful incentives for hospitals to pull in patients, but it may undermine collaboration between organisations3 or create conflicts between NHS trusts and primary care trusts.4 And the evidence so far on practice based commissioning (where general practices are given control over their commissioning budgets for secondary and community care) indicates that only modest efforts have been made to redesign primary care services to counteract the pull of hospitals.5
If the recommendations on the models of care are translated into diktats about the number and location of facilities, they will be seen as yet another “top down” exercise. This could cause planning blight by alienating clinicians and encouraging local commissioners to look up for instructions instead of working out their own solutions with providers.
London's health services have not been short of blueprints and plans,6 including some from our institution7 8 and others such as the Tomlinson report.9 Most of their proposals foundered on the near impossibility of implementing reforms that seemed to offer much to primary care and little to hospitals. This time, there can be no doubting Sir Ara's determination to let the power of evidence overcome institutional inertia and rivalries. But if this review is to succeed where others have failed it must empower local commissioners and clinicians to use the incentives that have been built into the NHS. And if it is necessary to strengthen, amend, or realign those incentives, that too must be done.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.