The re-engineering of health systems requires traditional barriers between primary and secondary care to come down, writes Tristan Reuser

Healthcare is a political issue, and will always remain so, in any country. The current government has made it the centrepiece of its reign, and has genuinely attempted to re-engineer the operational part of it, though not the principle of public funding and delivery free at the point of use.

Key words in the policies over the last few years were: new contracts for doctors, more doctors and nurses, standards, regulation, IT development, public involvement, more capacity, shorter waits. The central theme in all these initiatives was top-down management.

Too little consultation with staff working at the coalface while this multitude of policies was designed and implemented, has led to the situation we are at now. The capacity gap analysis has left local health economies with a huge surplus in capacity, at enormous expenses to the taxpayer. I would argue that provision of this surplus capacity is a good example of how to implement policy without staff involvement leads to solutions that are not required, at a high cost to both the taxpayer, and patients.

Engaging clinicians
The Department of Health.recognised that IT systems needed to be re-engineered from the ground up, and yet exclusion of significant clinician and patient input now seems to result in a system that will most likely not work as it was intended. There is neither clinician nor patient buy-in. Again, the mistake is being made, against the wishes of the public, of forcing a solution that some would see as an infringement on privacy. Clever spinning has not hidden that in fact privacy issues are not allowed in the debate.

Yet, when the NHS operating framework for 2006/07 was published it was recognised that it is crucial for the top-down approach to be changed to a more local one.

The big question at the moment is how to engage clinicians in this game. Commissioning care at a local level can only happen if there is buy in from the persons who are involved in care both at the higher level (when commissioners create a menu of providers they wish to commission with), as well as at an individual level (as in practice-based commissioning) when patients sit opposite their GP and choose where to be treated.

Prime minister Tony Blair commented at the launch of the PCT network2 that 'this is a watershed moment when we pass from one type of system to another'. He also recognises the importance of clinicians as he hopes that 'clinicians will become ambassadors for change and improvement', but also that there are no standard national recipes that can apply, and 'in each locality it will be up to you in the PCT'.

Importance of teamwork
Although Michael Porter's book on redefining healthcare was summarised as bringing (part) of the solution of the US healthcare problems, it was not thought to bring us in the UK enough help. However, his plea for stopping zero sum competition (where value is not created but merely costs are shifted), is a truth that holds in the NHS, too. Currently there is only one driver for change on the PCT horizon: budget deficits. This driver will become even stronger when the cash splash stops in 2008.

For the process of adding value rather than shifting cost to work, teamwork is essential. Integrated care, in this sense means that clinical teams are formed across the traditional boundaries, the finance of the care pathways is properly costed, and lines of clinical accountability have been clearly established.

Models of shared care (between primary and secondary care) that have been published on NHS network website as leading the way are still lacking profusely on the critical parts: they have not been properly evaluated, or they have not been properly financially modelled.

Clinical governance issues and proper financial modelling are being ignored in a way that would not happen in any well run private institution. Ophthalmology work done 'in the community' is not necessarily closer to the patients, nor necessarily cheaper, and certainly not always safer. There are, however, at the moment schemes being introduced by PCTs, that are very ill thought through.

Without boundaries
The driver is finance, and usually the lack of it in PCT land. The sad thing is that these new ways of service delivery are hailed by their proponents as efficient, and therefore financially attractive, whereas in the next few years it will become clear that current implementations will lead to more financial problems, not less.

Clinician engagement is not impossible though, and there are organisations that have started the process of providing information that will be a basis for further local discussion. The Association of Ophthalmologists have shown their view on commissioning with their clinical guide for commissioning ophthalmic care.

Truly boundary-less behaviour across the traditional divides between primary and secondary care is vital. It is now the time that clinicians grasp this nettle, and that both politicians and commissioners recognise this. Indeed, Professor Sir George Alberti, the national emergency care director acknowledged that 'managers are not believed, instead clinicians must lead'.

Tristan Reuser is clinical director, ophthalmology, at Heart of England foundation trust and past treasurer of the Association of Ophthalmologists.