Surgeon puts capital at cutting edge of policy

Like it or not, things often happen first in London. New fashions hit the streets first, films are released first and the capital is seen as the centre of government and the media.

And last week new junior health minister Professor Sir Ara Darzi published his first review of the health service - one he began long before joining the government - outlining changes he believes are required in London.

The vision in A Framework for London is in line with the objectives outlined in the 2005 healthcare outside hospital white paper Our Health, Our Care, Our Say, but it is more prescriptive about how care closer to home should be delivered and how hospitals should be reconfigured.

If Sir Ara has his way, 'one-size-fits-all' district general hospitals will soon be a thing of the past. Super-GP surgeries, so-called 'polyclinics', will be the hub of primary care provision. Large numbers of GPs would work in the centres, which would also provide mental health and social care, diagnostics and consulting rooms, and a 24-hour urgent care centre to act as the 'front door' for accident and emergency.

Now that world-renowned surgeon Sir Ara has been elevated to government, could his London review have implications that reach far beyond the capital? And does last week's report offer clues on the shape his NHS-wide review, commissioned by prime minister Gordon Brown and health secretary Alan Johnson, might take?

Sir Ara insists that healthcare provision in London needs a unique overhaul, and that his London review is 'not at all' an indication of the outcome of the national review. As he told HSJ on its publication: 'The reason for a London review goes back to the strong statement that London is different from the rest of the NHS.'

But he agrees that elements of his work in London will feed into the national review. 'There will be certain things we have learned which will inform the NHS review, such as clinical evidence will be the same as national clinical evidence and the best care pathways for stroke can't be different,' he said.

'But I am not saying the delivery models will be the same for the rest of the NHS.'

However, as NHS Confederation policy director Nigel Edwards puts it: 'It would be funny if he didn't come to the same conclusions [in the national review].'

The prime minister will have been privy to the report at its various stages and therefore must be comfortable with its proposals and the direction of travel in policy terms, he added.

Most significant among Sir Ara's recommendations are his plans for primary care, Mr Edwards says. The introduction of polyclinics will require 'very significant discussion'.

'The independent nature of primary care, the fact that some GPs are single-handed as they want to be and a lot of GPs own their premises could be a real stumbling block,' he explains.

GPs' responses so far bear this out. British Medical association GPs committee acting chair Dr Laurence Buckman says the idea of bringing GPs together in a polyclinic is anathema to them. What's more, he is furious a surgeon has made assumptions about general practice.

'GPs are not pawns to be moved around a chess board,' he fumes.

In his view, the London report will be implemented and the national review, probably 'already written in someone's head', will mirror the London review.

National trend

To inform the report, Ipsos MORI surveyed 7,000 Londoners. Public affairs managing director Ben Page says the findings show London is a 'challenging place to deliver care'. In part this is due to ethnically fractionalised communities.

He says the public often feels national policy is driven by problems in London, citing education as an example. But the London review is in line with the national trend towards moving care out of hospitals and into communities.

'We will have to wait and see, but I can imagine polyclinics being established, with big acutes in decline. Lots of areas are actually starting to do it closing district general hospitals.'

But any move in this direction would require careful management, he says. 'People will defend their local hospital to the hilt for reasons of convention and local affinity.'

The old adage 'trust me, I'm a doctor', could well be invoked here. Asking a renowned clinician to carry out the reviews could help convince the public, both in London and nationally, of the value of reshaping the health service as well as getting clinicians on side, according to Institute for Public Policy Research associate director for public services Richard Brooks. The growing number of clinicians leading the argument for change would help prevent the public from thinking it is about short-term costs.

'The report is led by clinicians who enjoy a much higher level of trust from the public,' he points out.

'It's important for the rest of the country that there are clear clinical reasons for reconfiguration services, certainly in big cities, from trusts down to a local level.'

Strategic health authorities throughout the country should take note, he adds. 'It's got to inform SHA plans as Sir Ara is now a health minister and if you're an SHA you will want to check what you're doing is right.'

The model for other areas may not be the same, but the thought process could be. 'If you're an SHA working up a strategy for local provision you should ask yourself: how did the new health minister approach these questions?' he adds.

Mr Brooks decries local reconfigurations that try to 'warm up' the public with the offer of everything staying the same, which is 'not really an option'.

He argues: 'The health service needs to change. People don't understand whether [a service they are defending] is good or not. We need better information but then they don't trust that. There are three great myths in the NHS: that there is no rationing; no risk; and no variation.'

Ensuring there is new provision before scrapping the old system will also be vital, many argue.

National Primary Care Research and Development Centre deputy director Professor Bonnie Sibbald comments: 'If a local hospital closes I think people will need a bit of reassurance. Before that happened a nice polyclinic should open first.'

And she feels the shift of care to the community requires significant investment: 'If you move care out of hospital and into the community it's not just a case of everybody picking up their things and changing building. We will need more health professionals in different locations around the community.'

Going super-skilled

The viability of hospitals could be threatened if more doctors began working in centres such as polyclinics. But it would have benefits too 'as the hospitals that are then left are super-skilled in what they do. Doing this will be challenging and require upfront funding and retraining for new roles'.

For Professor Sibbald, the report 'bodes well for the whole of the NHS'. But the strategy in the London review would be easier to apply to large urban areas.

Imperial College London faculty of medicine principal Stephen Smith says that although Manchester and Birmingham have much smaller populations than London they face similar issues with deprivation. Here, the London review could be particularly helpful.

He says: 'The report recognises global trends in medicine. If the UK wishes to have a healthcare system convenient to patients which delivers better outcomes, we should be looking to our competitors' organisational systems. The report's model is well developed in other countries polyclinics are working in Germany and the US. How fast it goes is a more practical question.'

Birmingham University professor of health policy and management Chris Ham praises the review as a 'rational approach reflecting what people have been proposing for a long time'.

He echoes the feeling that the review's recommendations will be much easier to apply in cities rather than 'medium towns and rural and dispersed areas'.

For him, the review marks the start of a new era: 'The report represents the rebirth of planning. During the last 10 years planning has not been part of the NHS vocabulary plan for healthcare in London. Each SHA should be producing a plan which reflects the London review.'

If the hurdles of GP outrage and public opinion are overcome and the London review is implemented, the new NHS trends could hit the regions not long after.