Despite a bad press, national targets have challenged our complacency about poor health in poor people and poor services to support them.
The requirement to deliver the same standards in access or meet smoking cessation targets across all areas has significantly improved expectations for some of our most vulnerable populations.
However, in practice, there are tensions between national requirements and local priorities.
We also have to manage the complexity of concepts of quality in healthcare. Back in 1986, medical writer Robert J Maxwell identified six aspects which are, again, in tension: effectiveness, equity, efficiency, acceptability, relevance and access. All are equally important but some are consistently given a higher priority in national policy, frustrating those seeking to make a difference on the ground.
As chief executive of a primary care trust where about 1,500 people die each year from diseases of the circulatory system and too many die up to 10 years earlier than elsewhere, I have a focus on tackling coronary heart disease and improving the life chances of children.
These are national targets, as is mortality from cancer. Many of my population do not survive long enough to develop cancer so, at a local level, we would like to prioritise tackling CHD.
Last year, our single greatest new investment went on a drug for breast cancer. This was nationally required but, even if the manufacturer's PR is to believed, is unlikely to have a huge impact on male life expectancy or infant mortality. If I were in Berkshire, my priorities may be different.
National and local interests coincide on the big goals of life expectancy and inequality of outcome, and in speed of access. They also want public money invested in interventions that work.
Locally, though, we are concerned that investment meets local need.
The national emphasis on access often overrides this. Worse, it puts access for all above acceptability to the patient. Far too much medication ends up in the bathroom cabinet because the 76-year-old diabetic, on warfarin, with chronic kidney disease and arthritis, cannot face eating 20 tablets a day.
To help improve our performance on male life expectancy, we mapped the prevalence of CHD. Rather surprisingly, it was concentrated in the wealthier suburbs; our diverse, mainly south Asian population seemed surprisingly disease free.
We then mapped mortality. People were dying in the very area in which no disease existed. Our most disadvantaged populations were served by practices which had been unable to systematically identify and manage heart disease. This second map showed the consequences.
Much of the time, the issue is the organisation of services. This is particularly the case regarding chronic-disease management and core healthcare support.
We must also understand that those most in need are those least likely to respond to a terse letter requiring them to attend an appointment. This is not to say they will not use health services but may be resistant to using services in a way that we deem appropriate.
The historic dominance of acute medicine has tended to emphasise: the individual patient at the expense of the population; technical evidence in relation to the new rather than the old; and, particularly, the introduction of pharmaceuticals rather than the review of processes.
The high tech consistently trumps the low tech. Witness the allocation of growth monies into specialised services in each of the last five years (10 per cent-plus above inflation compared with 1 or 2 per cent in community services). We invest in ever more specific and small populations with ever more expensive interventions, the apotheosis of which is enzyme replacement therapy: spend up to£250,000 a year on one person without evidence of effectiveness because the numbers affected globally are too small to support randomised controlled trials.
It is no wonder that we each consume 90 per cent of our lifetime NHS costs in the final six months of life, disproportionately beyond the point where it will do any good.
Last month, oncologist Professor Karol Sikora noted that if we made more time available for clinicians to talk to dying patients, we could probably save 75 per cent of spend on cancer drugs. At the moment, in 10-minute consultations, we prescribe beyond any hope of impact. If we prescribed the drugs only for those in whom they might have an impact, we could afford an entire team of people to have the conversations.
We need greater equilibrium between national requirements and local priorities if we are to address inequalities in health status and outcome and our tendency to treat more than the individual might choose. An outline for this would include:
- vigorous decommissioning and peer clinical challenge to work of limited clinical value alongside the introduction of the new;
- rigorous adoption of what we know works - to what extent are the 10 high-impact changes in place? - and a greater interest in reviewing and publicising processes as well as drugs;
- a challenge to waste: over 70 per cent of outpatient referrals end in no further hospital action and one PCT spends£63m a year on emergency admissions (each chronic disease admission is a sign of system failure);
- ensure we apply what we know consistently, and be sure that the patient intends to comply; and
- a greater concern with supporting people through morbidity, rather than rescuing them from early mortality only to abandon them to years of isolation, discomfort, pain and incontinence because we haven't any money left for social care or community services.
Delivery of the above would lead to a very different health service. If we are to survive a return to investment of 2-4 per cent growth per year, they will be essential at both a national and a local level.
Sophia Christie is chief executive of Birmingham East and North PCT.