Mark Goldman on shifting healthcare into the community

No criticism here of primary care. No primary care trust effort has been spared to improve and change the availability of community and primary care. The point is that it simply has not released the resources from hospitals that are essential to balance the financial equation.

The bold among you will make a case that we have yet to see the full return on efforts to date, that we must give it time and await the consequences of Lord Darzi's review and his polyclinics, or the longer-term effect of the GP contract and the quality and outcomes framework.

Perhaps logic would propose that a continuing pressure on hospital access has increased elective and outpatient activity and that there is just an "18-week bulge" working its way through the system. If so, it is a distortion that should end this year.

Accident and emergency

To remove the access effect, a good area of activity to focus on, a proxy is in accident and emergency, the core business of any district general hospital. Here, activity continues to rise and rise. In Birmingham, if we are to judge the onset of winter by increased A&E activity, then this year winter followed directly upon the green shoots of spring.

Policy is created by professionals, professional pressure groups and politicians. Policy making is a craft that thrives on a high-level judgement of what is best for the population. If the outcome is higher taxes or going to war, then there is little the common man can do about it. There are other policies that are more permissive and allow the electorate to exercise a view.

Right now, we are awaiting the outcome of the policy of releasing government borrowed money into the economy to stimulate more borrowing and spending by individuals. It may work. Some economists say it will work. The problem is that this is not automatic. There is a "known unknown" - the behaviour of the consumer. What will the customer do? We just do not know.

Community care

Healthcare faced a similar policy moment eight years ago. The judgement then was that patients preferred to have as much of their healthcare as possible managed outside hospitals. I was part of the groupthink of that time as then health secretary Alan Milburn's 10-year modernisation plan was formulated. Since that moment, various reviews, diktats and supplementaries have been added without diminishing this central presumption.

A whole vocabulary of alternatives has sprung up to support care in the community. Need I remind you of NHS Direct, walk-in centres, extended GP hours, minor injury units, polyclinics and so on? And still the people come to the old familiar local casualty department, where most are seen quickly and successfully. The pull of the tried and trusted local hospital remains strong. Hospitals are not what they were eight years ago.

A&E departments have changed so much they are hardly recognisable. The effort to do so has been stimulated by imposing on them the most difficult target of all: the very intimidating 98 per cent four-hour wait.

Inspired by a clinician, the target has single-handedly driven resources and attention into what was once a Cinderella service. Revenue and capital have poured in. Layer upon layer of re-engineering has been applied with extensive academic analysis of how best to manage this service. In the case of my own organisation, this includes real-time tracking of individual patients through three A&E departments across three sites, available on any PC anywhere in the organisation.

Disconnected system

The alternative community system is a novice by comparison, an immature disconnected system managed by different agencies. The longer the alternative community-based services fail to capture the imagination of the public, the more likely it becomes that A&E will prevail and the rest will collapse. Patients are exercising their right to choose and are expressing confidence in the hospital.

And suddenly another key element has changed. The financial model has been completely undermined. Prompted by the inevitable diminishing of resources, something decisive and not previously predicted has to happen in the next two to three years. The NHS will have to make a choice and it is likely that the public will be the arbiter. Either the public will switch their allegiance to community services or financial pressures will begin to erode the rationale for these newly established underused alternatives. Moreover, by then, commissioning PCTs will have no loyalty to services they may have initiated to satisfy a policy imperative. Judgement will be made purely on quality, patient satisfaction and value for money.

If John Lewis is the bellwether of public preference in the retail business, then A&E is the barometer between hospital and community. Moving the orientation, the pivotal point, of the NHS from hospital to community was always going to take time. No fault of the public, the policy makers, the professionals or the politicians, time may be running out. Strange to tell, when the story of the next 60 years of the NHS is written, it may be the private sector bankers who are deemed to have made the longest-lasting and most significant contribution to the reform of the NHS.