Malcolm Lowe-Lauri on following Darzi

Malcolm Lowe-Lauri

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I have been hearing talk along the lines of "Darzi will never take off". Some of this is wishful thinking (fearful acute trust) or something like first night nerves (empowered but apprehensive PCT).

Both perspectives seem to imply the health minister's next stage review aims for a world that otherwise wouldn't exist, that it is leading public and NHS opinion. I suspect it is following as well as leading.

It is the right time to ask questions of all parts of the health system when they don't work well enough. Look no further than healthcare acquired infections. We knew we had a problem, we had very clear explanations for why, but it has taken public intolerance for us to sort it out.

Implementation of Lord Darzi's recommendations is inevitable because it reflects society's keenness to upgrade its health system.

Acute trust leaders must prepare for a challenging phase. We must recognise that domination of health services by the supply side, particularly the acute supply side, is coming to an end. This is an uncomfortable idea for acute chief executives. But it will help out-of-hospital development along Darzi (and Our Health, Our Care, Our Say) lines; it will also help hospital development.

The term hospital connotes the same thing wherever you are. The information on outcomes following, say, heart attack or stroke says this ain't so. We must go through a differentiation period for our patients' sake: some hospitals must dispense with less good emergency services ("centralise where necessary" in Darzi speak).

Public opinion

In my mind's ear I hear reminders that the public likes its local hospitals and resents threats to their current constitution. When the public becomes a patient or a friend or relative of a patient, or a well informed foundation trust member, it likes to get the best available. In south east London patients who have had heart attacks and stroke have for several years been taken across borough boundaries to access the 24/7 facilities at King's College Hospital. I don't recall public indignation at the move.

You could say the university hospital need not worry because it's the inevitable hyper-acute provider. And there's plenty of demand for tertiary, ICU-related activity to replace real estate used for patients with long-term and minor conditions. A district general hospital may feel differently if it loses both complex emergency and outpatient-based services.

But there is another way to view this. Playing God's advocate and assuming a good tariff unbundling deal, there's a chance to develop as a knowledge centre instead of a traditional outpatient department operator. Perhaps working with clinical colleagues to act as advisers to other professionals working in the community, or even patients in their own homes (with the benefit of digital technology) as a virtual service (I nearly said acting as a consultant!) can be more rewarding to patients and professionals alike.

At an organisational level there's a chance to think about vertical integration as primary care trusts develop distance between the commissioning and providing functions. Alternatively, we could see imaginative partnership models with third and independent sector players to support migration from the hospital outpatient department.

Plans without action

Another inevitable whisper from my mind's ear is "we've had plans to move services out of the hospital for decades but it never happens". I can remember documents such as Prevention and Health: everybody's business which talked about just that at the end of the 1970s. The difference? Back then there was no contact between the public and that sort of discussion. We are now responding to a public that wants something more responsive than a big shed for the money it's putting in.

In my last 13 years as an acute trust chief executive, I have read hundreds of letters complimenting the work of emergency departments and inpatient services. I can count the equivalent for outpatients on the fingers of both hands. If this initiative is here to stay, acute leaders should grasp it and even lead it.

The first port of call will be our own workforce. There are already torchbearers in progressive trusts. Services such as chronic obstructive pulmonary disease, diabetes and dermatology already have inspiring leaders working towards partnership with primary care colleagues and patients. But within and between organisations we frequently get "the reason they could do that was..." and "we're different because..."

Pioneering work

Organisational sociologists call this "non-isomorphic", or not wanting to adopt the best of each other. Our task is to work with the pioneers and identify the next batch of enthusiasts across a range of specialties to create a head of steam. We also need to allow time for working across and between different parts of the provider side, using the expertise of "boundary spanners", who link systems. Their role is crucial, but rarely bankrolled. Acute chief executives can play a part of this role. They, fellow executives and clinical leaders will have spent time in this way as part of the next stage review process. There are already spin-offs in terms of clinical enthusiasm for new service models and other partnership projects like the national centre of excellence in diabetes here in Leicester.

This puts the acute trust into closer contact with civic, public and patient partners. Foundation trusts are growing experience here based on their governance arrangements.

As we work out our approach to the next stage review with our system partners, this intensifies our connection. Partners in the health system in Leicestershire work together with overview committees. This brings us into contact with politicians, patient panellists and local improvement network. We must propose, based on provider knowledge, but we must also listen, understand and respond. We must follow opinion but lead it too. We've always done a bit of this, but it will be much more the norm in future.