London has been in the eye of the storm of health service reconfigurations. Work undertaken following Lord Darzi’s 2007 review has begun to tackle well known weaknesses in how services are provided and a recent report from The King’s Fund identified progress made in implementing the review’s recommendations.

We also drew attention to the amount of unfinished business in London and asked who would lead this work following the abolition of strategic health authorities and primary care trusts.

The progress made in stroke care illustrates another lesson, namely the need to work at scale to make some changes happen

At a conference of health service leaders held at the King’s Fund last week, NHS London chief executive Ruth Carnall reflected on her experience of leading service change in the capital. Ruth emphasised the importance of articulating a clear and strong case for change to underpin work of this kind. She also highlighted the role of clinical leaders in taking forward this work with the support of experienced managers.

The example of stroke care by Tony Rudd, where outcomes have improved through the concentration of specialist stroke care in eight hyper-acute units, is a case in point. The progress made in stroke care illustrates another lesson, namely the need to work at scale to make some changes happen. In this case, collaboration both between providers and between providers and commissioners across London was required to secure agreement on where specialist services should be located.

Unsustainable landscape

Ruth also reflected on the disappointments and challenges experienced along the way. These included work still outstanding in some key areas such as cancer care, mental health and primary care. Even more important was the setback that occurred after the 2010 election when Andrew Lansley stepped in to halt the programme of work the SHA was leading. Notwithstanding the health secretary’s intervention, much of this work continued because NHS leaders and clinicians judged it was the right thing to do.

Important lessons from London’s experience include the length of time it takes to bring about changes in care and the risks that arise when national and local politicians intervene inappropriately. In the case of stroke care, several hundred lives might have been saved had changes occurred sooner. Similar arguments apply to changes in the role of local hospitals which in the case of Chase Farm in north London took around 20 years to be finally agreed. These lessons take on added importance at a time when the provider landscape in London is, in Ruth Carnall’s judgement, simply unsustainable.

On the issue raised in our 2011 report – who will lead work on service reconfigurations from next April – the jury is still out. In her presentation, Anne Rainsberry, regional director of the NHS Commissioning Board in London, reiterated the need for change to be led both bottom-up and top-down. In north west London, this is being done through the emerging clinical commissioning groups collaborating with each other to make the case for major changes in hospital services with the support of the NHS Commissioning Board. While this example is encouraging, Anne acknowledged that not all CCGs were yet in a position where they can work in this way.

One of my reflections on the day was the need for politicians to think very carefully about their involvement in service changes because delays and compromises can cost lives. While the urge to protect constituents’ interest is strong and understandable, it should be resisted where there is a clear clinical case for change. In considering what are ultimately life and death issues, councillors, MPs and ministers would do well to adopt one of the fundamental precepts of medical practice – “first do no harm”.

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