The regeneration game

For years now, the district general hospital has been under attack from primary care zealots. It has been characterised as a bastion of vested professional interest, impersonal and bureaucratic, with a voracious and indiscriminate appetite for new and expensive technologies.

A few well-publicised incidents of failed discharges, methicillin-resistant Staphylococcus aureus (MRSA), and clinical misadventures hint at generalised ineptitude, indifference and lack of care. And, as the NHS desperately seeks tools with which to manage demand, the DGH is fingered as one of the biggest culprits. It is accused of lowering admission thresholds, double-counting finished consultant episodes, and extending treatments well beyond what is proven to be effective.

Accused in this way - but without a fair trial - the zealots have sought to strip the DGH of many of its functions and re-provide them in community settings.

But such root and branch zealotry has probably peaked. A more objective analysis might suggest what most GPs have always known - that primary care is stronger and safer for having a local, responsive and viable secondary institution able to manage clinical risk, providing the ultimate 'safe haven' for the increasingly complex multi-pathology which presents in general practice.

Importantly, the recent white paper permits local GPs and the DGH to negotiate a new relationship.1 The New NHS confirms what many in the field have known for some time - that 'the internal market has over-emphasised the role of primary care as commissioner of hospital services at the expense of improving the provision of primary care services themselves'.2 The term 'a primary care-led NHS' is not to be found in the white paper.

Branching out, becoming relevant

The 'new NHS' is to be characterised by a 'whole-system', co-operative approach to the delivery of local general healthcare services with primary, community, social and acute care working together to obtain maximum clinical synergy and service integration. Within this new regime, the local DGH will have a clear choice.

It can retreat into a techno-clinical future and focus on a narrow interpretation of 'core business' - high-tech diagnostics, intensive surgical and medical services; or, in addition to this core role, it can extend itself and embrace other roles, thus becoming:

an active partner adding value to the work of professionals in other agencies;

a responsible employer ensuring that its employment and investment decisions resonate with local socio-economic priorities;

a health-promoting organisation directing its clinical firepower towards programmes, both within the institution and in the local community, which prevent ill-health;

a change agent working in alliance with local GPs.

The second course offers the best prospect for long-term survival and prosperity. It implies the creation of new, robust relationships with those partners - local authorities, client support groups and other local consumer interests - who were distanced and marginalised in the past.

But the richest seam most likely to achieve early success in service improvement is joint working with local GPs. Indeed, it is clear that there are tremendous opportunities for local GPs and the DGH to form a powerful and mutually supportive clinical alliance which goes beyond mere ministerial exhortations to co-operate. A new common language - or more likely the discovery of an old and forgotten language - will bind this alliance. It will stress the primacy of service development, integration and quality, and will increasingly devalue the FCE as the measure of the system's 'efficiency'.3

Incentives and clinical innovation

The overriding incentive for GPs to form such a clinical alliance is obvious - improved, less bureaucratic and more sensitive local acute services. In short, an easier life for them and for their patients. The overriding incentive for the DGH is that its services will be endorsed clinically, politically protected and financially supported by GPs as local commissioners.

The strategic purpose of such an alliance would not be to monopolise clinical opinion and thereby increase leverage locally - although the local health authority will harbour such fears. Rather, it would be to create a non-threatening evidence-based professional framework within which rapid clinical innovation and service improvements can be achieved.

The New NHS heralds a regime that will give local GPs and the DGH common cause. GPs, as commissioners within primary care groups, are to be performance managed. Despite assurances that this will 'not affect their independent contractor status', it is difficult to see how this squares with the pronouncement that 'the new NHS will be performance driven'.4,5 Whether intentional or not, performance management is a threatening process. It will prompt GPs and specialists to work together to deliver within such a framework.

Similarly, the extension of the clinical effectiveness agenda will, sooner or later, lead to a focus on the duplications and gaps in service between local primary care and acute services, which only genuine joint working can resolve.

A new paradigm for the DGH

For such an alliance to be built, much must be done by the DGH to change its world view. It will need to:

dis-assemble and re-assemble the perceptions which many specialists have of GPs within the previous regime. Role conflict between fundholding GPs as short-term commissioners and specialists as long-term providers has damaged these fundamentally important clinical relationships;

end its preoccupation with re-engineering hospital-based short-stay surgery. Advances in this field over the past five years have been at the expense of the DGH surrendering its role as lead provider for the local management of emergency care across the primary, community and acute sectors;

place more emphasis on discharge from, rather than admission to, the DGH. Driven by market share considerations, previous corporate effort has been directed at facilitating admission. Failed or blocked discharges were (and still are) blamed on the shortcomings of the other caring agencies;

orientate the trust board away from a crude focus on the institution's corporate risk management and the protection of its assets. Such a focus has done so much to fragment the delivery of services and distance the DGH from its provider partners;

understand the diversity of primary care - its distinctive history, traditions and practices that vary from neighbourhood to neighbourhood - as a precursor to the delivery of more sensitive services. This will be particularly difficult given that the DGH is now increasingly geared to delivering care within ever more standardised systems and procedures.

Demand management

But it is in the sphere of demand management where the value of the clinical alliance will ultimately prove itself.

Previous attempts to manage demand across the spectrum of care have failed because the strategic interests of the key local players have not been aligned. However onerous the frontline pressures, it has been in the DGH's financial interest to accept increases in emergency and elective caseloads, as they enabled it to build and maintain critical mass.

It can be argued that the clinical pressures in general practice are more burdensome than for the DGH. Unlike the DGH, general practice does not have the critical mass, the flexibility or the substitution strategies to manage its ever-increasing workload. Both sectors are currently locked into a financially unsustainable trajectory. But two developments will begin to align strategic interests in the local management of demand: in 1998-99 the DGH will have, for the first time, the surety of an agreed annual workload and income free from the turbulence of fundholding; and The New NHS commits the government to replacing the current efficiency index and the FCE as a unit of currency.6

While by no means sufficient in themselves, they signal what will be possible in a much less volatile healthcare environment. With the financial bottom line secured there will be positive incentives to manage demand. In the shorter term it would be possible for the alliance to:

agree local clinical priorities;

negotiate new (ie higher) referral thresholds;

develop new and expand existing one-stop, rapid-result diagnostic services;

introduce phone helplines, encourage client support groups, and create more nurse practitioner-led services.

From here it is only a small step to admitting the folly of perpetuating two distinct and separate local emergency services - one in primary care, the other the local accident and emergency department.

The right course

The New NHS has at its core a 'soft' vision of primary and community care where consensus and multi-agency agreements are strong features. It would be only too easy for the DGH to underestimate the potency of this, and to retreat and define a discrete future for itself on its own terms. Such splendid isolation is strategically dangerous. Moreover, the DGH would then have failed to maximise the opportunities for clinical synergy and service integration which working in alliance with local GPs makes possible.

The DGH must come in from the cold. It must learn to add clinical value in new and different ways, making its contribution to the delivery of local healthcare self-evidently irreplaceable. Crucial to this is the creation of the local clinical alliance forged to bring about change that reshapes local health services - not to defend the status quo. Change which will be consensual, inclusive, clinically owned, and incentivise the players - the essence, that is, of textbook change-management.