Essential insight into England’s biggest health economy, by Ben Clover.

Some questions on the ‘fundamental shift’

Yesterday saw the first public airing of Journey to a New Health and Care System, Sir David Sloman’s plan to re-model London’s NHS in the (hopefully) wake of the covid-19 pandemic.

There are quite a few unanswered questions prompted by the document, which sets out a rough plan tofundamentally shift the way we deliver health and care”.

Here are a few:

  • It says this process will be “provider led” but also that it will “radically shift care away from hospital care”. Call me cynical but the more powerful providers tend to be hospitals. The senior medics that lead their service lines have not been at the forefront of moving their work out of hospital.
  • It’s hard not to be alarmed at the idea that we have to “accept a different kind of risk appetite than the one we are used to. What kind of risk? Which patients are going to be facing potentially less safe services in the new world? This line was from the “risks” section of the document, which said the workload post-covid might see a “reversion to the priorities, approaches, structures and behaviours of the past”. Perhaps the kind of “risk” we should now have an “appetite” for includes things like the risk from patient initiated follow-ups (“sorry if you thought you would be notified about a routine follow-up that turned out to be quite important, you are supposed to tell us”). Although to be fair, London’s NHS is going to have to do a lot of prioritising over more urgent issues than routine follow-ups. We could already have hundreds of cancers gone undiagnosed that would otherwise have gone in on the urgent two-week pathway.
  • “London will focus on setting the conditions for the ICSs to succeed – Setting standards (eg clinical standards)” – which clinical standards is NHS London thinking of setting? In consultation with whom?
  • A “new approach to public consent”? It’s not very clear what this means. The NHS has never been very democratic, so perhaps a new approach is to be welcomed? It’s just not clear how this will sit alongside legal things like the statutory duty of consultation? The implication of the document is very much “We need to be ready for the next pandemic, recover services and keep the best of what we’ve already changed, urgently” – could be wrong but it doesn’t sound like the “new approach to public consent” will be a more comprehensive approach to public consent. Nevertheless, the case to the public that “we need to change services because of the coronavirus” might work for some things (“We’re moving routine T&O out of Stanmore”; “Okay, whatever”), it’s going to look strange for some other parts of the programme (“One outsourced pathology/pharmacy arrangement for all north central London,” for example.)
  • There’s a laudable commitment to “disproportionate focus and resources for those with most unequal access and outcomes” in the document. What levers will the new system have to do this? Some local leaders see it as their job to protect the resourcing of their area from attempts to shift services elsewhere, where there may well be more need. This has undone previous cross-borough partnerships.

(I am curious to hear your questions, or thoughts, on Journey to a New Health and Care System. 

A bigger question

The bigger question is whether the new system will be better placed to protect Londoners from another pandemic than this one was.

Credit to everyone involved in the ongoing crisis but it’s worth reflecting on what we would do differently next time.

For example, the Nightingale hospital treated 54 people while hundreds of people died perhaps preventable deaths in care homes across London’s boroughs.

Social care is not part of the NHS but it does fall under the remit of the Department of Health and Social Care. But the lack of protection for care home residents, for care home workers, did not seem to exercise anyone with power until quite late.

Will Sir David’s new system protect this population better next time? Maybe if ICSs are beefy and powerful next time and work effectively with the local authorities who are supposed to have them as members.

But is anyone really going to be happy with a localised version of the central decision to empty hospitals, filling care homes with potentially infected residents? That say, north west London does this, and south east London does not?

Who is actually going to have the authority if councils say no?

The first of the “eight tests we must meet” is titled “covid treatment infrastructure” and lists things you might expect like increased critical care capacity, a surge capacity for workforce and equipment.

But the “strict segregation of health and care infrastructure” seems to mean within hospitals rather than between hospitals and the care sector.

I think there is something worth highlighting from the introduction. The author writes: “In the initial phases of the pandemic, the rate of spread in London was faster than the rest of the country. The NHS and local government moved rapidly to expand critical care capacity, distribute supplies, implement new models of care and support for the most vulnerable eg care home residents, homeless people” (my italics).

Local authorities in London took quick action to help homeless people, putting hundreds into hotels. I’m not sure “new models of care and support” were in place for care home residents, and certainly not universally.

In fact, the key point of contact between health services and social care was contentious.

Will this be different next time?

Probably not unless the law is changed and social care is nationalised.