“The language of priorities is the religion of socialism” – and the NHS, Nye Bevan might have added.
Decisions about both politics and healthcare, which look relatively straight-forward to even informed observers, tend to be much more complicated up close. Healthcare, again like political ideology, is something that stirs up emotions which often prove a double-edged sword when trying to make delicate judgements.
HSJ’s revelations that best practice in paediatric cancer services is in conflict with an unusual service model with the world-renowned Royal Marsden Foundation Trust at its heart is a case in point.
To simplify: the problem is that the Marsden’s Sutton hospital does not have a paediatric intensive care unit and therefore has to transfer very sick children to other hospitals, several miles away, fairly regularly. No other major provider of these services in the UK operates in this way.
National Institute for Health and Care Excellence guidance from 2005 states children treated at cancer centres must have immediate access to intensive care. There has been almost universal agreement among the foremost oncologists and medical leaders for over a decade that paediatric cancer services should be co-located with an ICU.
For the same amount of time, the Marsden has resisted that view – knowing it would mean significant upheaval and cost for them or – very likely – eventually losing some of their services and income. That view has been backed by the Department of Health and Social Care, and NHS England, which have understandably recoiled at the idea of undermining one of the service’s best-known providers.
Since 2015 Marsden chief executive Cally Palmer has also served as NHSE’s national cancer director – which has inevitably brought about a conflict of interest.
So how should the NHS “speak the language of priorities” in this difficult and emotive case?
The weight of clinical opinion that co-location provides the best possible care is overwhelming – and HSJ has not spoken to one NHS leader or senior clinician who believes otherwise. This does not mean the care provided under the Marsden’s model is poor, despite the number of disturbing cases emerging, it simply recognises that it could be better.
The second-best position which NHS England is insisting on throws shade both on the quality of cancer services nationally and the Marsden’s international reputation. Therefore, the standards, as designed by clinicians on the recent clinical reference group, must be rewritten to state their original intention that co-location is “a must”.
But the idea that children with cancer should not be treated at the Marsden is plainly ridiculous. What is needed is a clear-sighted acknowledgement that a solution must be found, and the trust and wider system – with its London NHSE commissioners – then given time to put it in place.
HSJ has been told NHSE London previously brokered conversations between the Marsden and the Evelina London Children’s Hospital to deliver a “Royal Marsden @” model. This was supported by clinicians at both sites but did not proceed, it is said. Revisiting such a proposal would now seem sensible.
Finding a solution will involve some swallowing of pride and rowing back from entrenched positions on all sides. It is one of the few cases where the direct involvement of the health and social care secretary as an honest broker would be welcome.
The situation has been at a standstill for a decade. The debate is characterised by briefing and counter briefing, and by nods and winks from influential people intended to signal the conclusions decision makers should reach. Mostly, the motivations of those concerned have been good, but just imagine how it looks to children with cancer and their parents. They deserve a more transparent and constructive dialogue.
It has been suggested that Ms Palmer step down from one of her two roles. HSJ does not believe those calls are justified by the information we have to date. The involvement of trust chief executives like Ms Palmer helps make sure policy decisions are informed by the reality of service delivery, as is also the case in mental health and women’s and children’s services.
But it is clear this row has placed Ms Palmer in a very awkward situation and HSJ is aware of other examples where chief execs also wearing a national director hat have been in danger of being compromised by the decisions they are involved in.
This situation cannot be allowed to persist or more complaints of conflicts of interest and cover-ups will emerge. It is time for the NHSE leadership to revisit how clinical evidence and best practice are represented in its policymaking; and set out how it will deal with quality and variation in specialised services – the £17bn sector over which it has direct control.
Simon Stevens at meeting which decided not to publish controversial cancer report
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Children with cancer need an end to the 10-year Marsden standoff