The strategic health authorities have set out their stalls but is there anything new in the proposals and are they likely to make regional variations in care inevitable? Alison Moore investigates
Wish list or blueprint for a better future? The regional Darzi reviews are a mixed bag, with high-flying visions alongside practical solutions. They vary in the number of specific pledges they make, how much they focus on public health and the extent to which their vision seems to be a centralised one.
There are numerous promises to pull regions up to at least average in many areas - from life expectancy to getting your five a day of fruit and veg, with NHS South West aiming to be the best in the country by 2013.
The reviews offer pledges, recommendations, targets or aspirations of some sort, although sometimes these seem to be a restatement of existing policies or so general that success or failure will be hard to measure. Some have a facilitative approach - setting out the general values or standards they want to promote - while others have timed targets.
NHS Confederation policy director Nigel Edwards says: “There’s an interesting divergence in approach between the reports. It will be interesting to see, as time goes on, which of these approaches will yield the best results.”
Probably the most directive report comes from the South West, where the pledge to complete elective treatment within eight weeks by 2011 is just one of a host of access targets to be met by specified dates. No-one in the South West could be in any doubt about what they are expected to have achieved by when.
Shades of grey
But the position is different for other areas. NHS North West talks a great deal about engagement and a “New Relationship” with the public. It has recommendations but they are often not timed and are less specific - for example, “the mental welfare of the population should be embedded in all services”. These recommendations are less prescriptive for the primary care trusts and other trusts that have to deliver them, but judging whether they have been adopted will mean discerning between shades of grey. However, the North West report provides 10 “touchstone tests” for the public to use to judge whether the region is delivering on its promises.
But just whose visions are they? Although all of the strategic health authorities have set up working groups that have shaped these reports, there is still concern about whether clinicians and others who will have to deliver the reforms have been adequately involved in the consultation paper. As one doctor put it, “clinically led” has to mean more than the medical director of the SHA being involved.
The British Medical Association describes the consultation as “extremely patchy so far. In some areas it has been abysmal, with no real engagement; in others it’s worked quite well and staff have felt genuinely involved. The overwhelming mood, however, is one of dissatisfaction or anger”.
The North East comes in for particular criticism. The region says it has “grand sweeping plans” but there is little detail, including around funding. Middlesbrough GP Dr John Canning says many of the doctors involved in the process have come from professional executive committees rather than the wider GP community. He feels that the resulting report is focused on aspirations, with some suggestions that do not appear very practical.
Policies and personalities
Practice-based commissioning lead for the NHS Alliance David Jenner is concerned that practice-based commissioning doctors have been overlooked, despite their potential for delivering on the visions.
For example, the South West access targets would mean more money going into acute care, leaving commissioning practices with little to spend on other priorities, he says. This could mean that evidence-based work on preventing cardiac problems and diabetes would lose out to improvements in waiting times for planned care for which there is no evidence base.
But NHS Alliance chief operating officer Mike Sobanja has a more positive view, saying there are anecdotal reports that GPs have been involved in the process. If this continues through detailed planning and implementation, it will be a very positive outcome, he says.
Inevitably, the visions raise the question of how far SHAs are pushing their own aims or trying to anticipate new government priorities - several suggest extensive health checks or schemes.
There have been discussions to ensure the regional reports are broadly in line with the national report, due on 30 June. Nearly all express support for a single access number for urgent care, for example, which was raised in the interim Darzi report. It would be surprising if any of the reports produced ideas that were totally outlandish or at variance with government policy.
Dr Jenner says the reports reflect “the personalities of the SHAs” - or more specifically their chief executives, as one commentator says: “You can see Ian Carruthers in the South West one and Mike Farrar in the North West one.”
Dr Jenner continues: “We may be in an era of no central directives but the new centralists are the SHAs. We have not got away from managerially led command and control.”
The way in which the reviews have been conducted suggests they are not necessarily an aggregation of PCTs’ visions in a certain area - which raises the question of how they will be implemented if it is PCTs, nominally at least, doing the commissioning.
Some SHAs certainly see themselves as taking on a greater performance management role. To some extent, this is inevitable if the broader messages of the reports are to be pushed through the normal constraints of finance, unexpected events and other priorities. This might be particularly true for public health initiatives, which have long pay-off times and may require money to come out of acute services,
Fuzzy on specifics
Faculty of Public Health president Dr Alan Maryon-Davis says: “The SHAs can play a vital part in making sure that happens. We need to make sure that whatever complex performance assessments framework is put in place, it ensures these aspirations become reality.”
This demands a lot of those at the top of SHAs, who may be under pressure from ministers over other targets. What priority will be given to local targets when there are high-profile national targets to be met?
Overall there is little about how the reports will be implemented, one critic says. There is also a sense of dej. “If I have read this all before, why has it not happened? What is going to be different this time?” he says.
For many patients and staff, the key question about the reviews will be how they will affect their local NHS hospital or surgery. Most of the reviews are fuzzy on the specifics, although some do offer reassurance. The South West report, for example, says it does not expect maternity units to close as a result of its new vision for maternity services. Several point to the geographical and demographic constraints they face, which may lead to different answers for different areas.
The SHAs are at various starting points: some have been through painful reconfigurations, while others may have work to do.
If these ambitious plans go ahead, the NHS in England will be transformed. There will be a greater emphasis on prevention, better integrated services and increased choice for patients. But will it be the same NHS from Newcastle to Newquay or will we have 10 mini-systems to add to the major differences that already exist between England and the other countries of the UK?
There is no straight answer. Nigel Edwards talks of “core similarities” in the reports. “There is a big emphasis on quality, measurement and changing the way that clinical services work rather than changing the structure,” he says.
There will be differences between areas - although the extent to which the public feels them will vary with age and condition - but they will not necessarily be any greater than the variations that exist now. If polyclinics go ahead, the experience of Londoners may be very different from that of people in other areas. Those lucky enough to live in the South West will be treated faster than the rest of us - although if they eat their greens maybe they will not need so many treatments.
But the real fundamentals - treatment as an individual; a service committed to safety and quality - should be universal.
Notable by their absence
Polyclinics seem to be fast becoming the love that dare not speak its name - and the word is rumoured not to appear in the final Darzi review at all. While some strategic health authorities seem to be proposing something close to polyclinics and there is universal support for providing more outpatient and diagnostic appointments in the community, the word is virtually absent in regional reviews outside London.
North West SHA talks of 24 GP-led health centres with “diverse services” while North East SHA says there will be major primary and community care facilities that will support the “care closer to home” drive. Yorkshire and Humber is proposing “virtual polyclinics”, envisaging specialists coming out of hospital and working alongside GPs, probably in existing buildings.
But it also says that providing “a wider range of access and services to reflect the needs of their populations” is likely to require “greater integration between practices”. West Midlands envisages some large surgeries covering 8,000-15,000 people and providing additional services - but it also sees some small practices continuing.
So what is a polyclinic and what is just a big health centre? Lord Darzi told the House of Lords recently that “the health centre is very different from the polyclinic the purpose of the polyclinic is to provide more integrated and personalised care and does not mean shifting GPs from their patients”.
There is also surprisingly little on healthcare-acquired infections and hospital cleanliness - despite the public engagement events where issues of cleanliness, infection and patient safety seem to have come up consistently.
As one report says, the public “simply does not understand why the NHS finds this so difficult”. NHS South East Coast makes a specific pledge on the issue - no avoidable infections by 2018 (2011 for MRSA) - reflecting public concern about this and the Maidstone and Tunbridge Wells affair last year. But what is avoidable? And what about the quality of treatment for patients who get unavoidable infections? Arguably, how well the NHS responds to an infected patient is just as important as preventing infections, especially where C difficile is concerned.
The private sector also tends not to be overtly pushed, although many SHAs see its involvement as crucial to delivering part of their vision. The North West, which has been one of the more active SHAs in adopting a neutral approach to who provides care, says “care should be provided by the provider best able to meet the needs of the patient, irrespective of whether they are an NHS organisation, as long as NHS values are maintained”.
And one or two you might not see again…
There are myriad case studies to show how care will improve for patients with different conditions - including an extended family from the East of England who could probably support a district general hospital by themselves. But do not expect an update on their condition if the promised improvements do not materialise, the integrated care is stymied by IT problems or the health, education and social care services do not work together seamlessly.
The North East report is proposing everyone should fill in a personal lifestyle questionnaire each year and have a health and well-being plan based on it.
GP John Canning points out that if this involves face-to-face patient contact, the average surgery would have to find 3,500 to 4,000 extra appointments a year - pretty much half a doctor’s time.
Prevention, promotion and early intervention
The NHS is predicated on sickness when it ought to be more concerned about health and well-being. The need to boost preventive services and to intervene more effectively during the early stages of chronic diseases feature prominently in many reports. The planning group for this stream in Yorkshire and Humber even suggests a 10 per cent shift in resources into this area - although the full report is lukewarm about this.
However, it is not immediately clear how improved health promotion will be funded. In particular, how will we fund better preventive services that will bring benefits decades later through a slimmer, more sober and smoke-free population while acute services are still feeling the impact of today’s fat, drunk and smoking cohort?
There are a lot of visions of a future with fewer health inequalities and a healthier population but no convincing road map of how we will get there.
Alan Maryon-Davis says it remains to be seen how the focus on public health will be reflected in action by primary care trusts and others. Previous attempts to prioritise public health have not always been followed through on the ground.
Resources and training will be needed to help the wider public health workforce to deliver, and to provide a strengthened public health workforce. But this could require diversion of money from the acute sector now.
Dr Maryon-Davis points to the support of both health secretary Alan Johnson and prime minister Gordon Brown for tackling health inequalities - and the Wanless report conclusion that health services risked becoming unsustainable. But there is little in the regional reports about disinvestment in acute services to release money for health promotion, and primary and community services.
“The pay-offs are often 10 or 20 years in the future. That’s of no use to politicians - or health service managers,” says Dr Maryon-Davis.
Primary angioplasty, stroke and trauma
Shake-ups in emergency care are likely to centre on locations for these specialist services. Almost all of the reviews were clear that improvements in these areas could lead to significant extra lives saved, but they will not be available at all acute sites. Work with ambulance services will be needed to ensure patients are routed appropriately to stroke centres and specialist heart attack units.
Doctors with appropriate skills will need to be based in these centres - which may require some of them to move trusts.
Specialist stroke centres are likely to be more numerous, with several per SHA area, while many SHAs are envisaging fewer heart centres.
Level one regional trauma centres are possibly the most challenging to establish, with the population of some SHAs only being large enough to justify one. Although they will take only the severe end of trauma cases, they risk being seen as draining work from local A&Es rather than adding a gold-plated level of care. Working within networks to provide care for seriously ill patients is also possible in some areas.
The College of Emergency Medicine points out that geography may mean some hospitals need to keep services that their population does not justify.
Dentistry was not identified as an individual theme for the reviews, but many picked up on the need for improved access. In some cases, this was driven by substantial public concern highlighted during consultation events. Increasing access will almost certainly mean extra funding.
Fluoridation is also mentioned: East Midlands SHA plans to consult on whether this should be done in its area.
The need to provide choice over where to give birth and better support for parents at all stages from pre-conception onwards is one of the most consistent themes of the reviews. While this may mean consultant-led obstetric services being concentrated on fewer sites in some cases, there is also renewed interest in midwife-led services.
In many cases this will mean women are further away from a consultant-led unit but can access a maternity-led unit. To what extent they will regard this as promoting choice is uncertain.
West Midlands SHA wants to buck the trend towards larger, centralised services and advocates keeping services local and sensitive to the needs of the community.
All this will mean more midwives are needed; the Royal College of Midwives estimates that 3,000-3,500 additional full-time midwives are needed to deliver existing commitments and several SHAs identify the need to recruit more midwives.
Payment by results
This needs reform to allow it to reflect what the NHS is trying to do. Many of the reports touch on this, with issues such as payment not reflecting outcomes or quality; the need to subsidise services in some areas (such as maternity units with under 2,700 births that are unlikely to “break even”); and the need to ensure that centres doing a lot of specialist work do not lose out.