There are too many hospitals swallowing up too much money for too little return. Which is fine until you try to close or downsize one, and all hell breaks loose.
Reconfiguration, or rather the lack of it, was perhaps Labour’s biggest failing. Without world class decommissioning, we don’t have the money for world class commissioning. We can QIPP and carp as much as we like, but unless we start merging specialist services, the NHS will remain as unsafe and unsustainable as it always was. Commissioning consortia are soon to inherit the commissioning budget, and the buck will pass neatly to them. But will GPs have the balls to make those difficult “Daily Mail camping on your lawn” decisions?
There are lots of creative ways to reconfigure
This is not a new argument for me. Ever since breaking the story of the Bristol heart scandal in 1992, I’ve argued that we’ve needed fewer paediatric cardiac surgery (PCS) units to concentrate expertise and resources, improve training and provide meaningful audit to show the service is improving. But 18 years later and we still haven’t reconfigured PCS, despite the huge public outcry and the largest ever NHS public inquiry. So what hope is there of reconfiguring any NHS service?
We’re now into our second PCS review and we’ve had another, entirely preventable, scandal in Oxford.
As a broadcaster, I’ve had some success nudging reconfiguration with campaigns for the centralisation of child liver surgery and cleft lip and palate repair, but among most GPs, the appetite to get involved in these debates has been poor. Ask managers who have tried to reconfigure accident and emergency or maternity services in the face of public opposition, and they will often bemoan the lack of GPs coming out and making the case for change
Open my copy of BMA News and out pops the headline “MP says reconfiguration will cause fatalities”. Does local MP Helen Grant really have the evidence to declare proposals by Maidstone and Tunbridge Wells Trust to centralise consultant-led obstetric services “are utterly wrong and dangerous”? Across the UK, 500 babies die every year during birth, often because they don’t have access to a consultant-led service when things go wrong.
Evidence is often the issue with reconfiguration. It is hard to make the safety case for a service that isn’t in existence yet, and it is hard to factor in the risks of extra travelling time over bad rural roads. But Ms Grant says 100 GPs have signed letters saying these extra risks would be “unacceptable” and that it is a “near certainty that some babies may suffer brain damage or die en route”. Meanwhile, not one GP has publicly made the case for reconfiguration.
The legal obligation to consult the public makes for a complex debate, but it can’t be bypassed. As always, we need the best data we can find to make the case and ask, say: “How far would you be prepared to travel to a unit that has half the mortality rate of your local unit?” My experience is that parents will travel the Earth for their children, and increasingly for themselves.
There are lots of creative ways to reconfigure, with hub and spoke models, satellite units and the best IT links, but the bottom line is that the arguments - both for and against - have to be made to the public by people they trust. GPs are in the driving seat now, and it’s a challenge they mustn’t shirk.
Fortunately, there are some out there leading the way. Kosta Manis, a South London GP, has designed a rapid access chest pain clinic in the community at a cost of £800 a patient compared with £1,500 charged by local hospitals. In the first seven months of 2010 his HSJ Award winning idea saved Bexley Care Trust £300,000. The trick was to cut out the secondary care “middle man” and form close partnerships between primary and tertiary care. Consultants from Guy’s and St Thomas’ run clinics in four surgeries and, if needed, the patients get door to door transport to the European Scanning Centre on Harley Street for a state of the art scan. It’s faster, safer, cheaper, more convenient and all on the NHS. Patients love it, naturally.
What’s clearly needed is a chain of “Kostas” (maybe they could sell coffee too) challenging the block contracts of hospitals and freeing up pump-priming money for redesign. Once you’ve got a better service in place, reconfiguration is a much easier sell to the public, politicians and the press.