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Keeping the NHS local – a new direction of travel

British Medical Association
May 2003

Summary
The view that service rationalisation must encompass closing some services was until recently accepted by government as well as the medical profession. This document reflects a major change in government policy direction and, whilst it appears driven by political concerns rather than solid evidence, we accept that it is for politicians and the public to set the direction of policy and for the medical profession to work within the constraints of that policy.

The stated principles of the document – shifting the focus from relocation to redesign, from individual hospitals to whole systems, and from designing for local people to designing with them – are welcome. However, political and public decisions must be based on adequate information about their consequences and wider implications, on an understanding that resource constraints will always place limitations on the service that can be provided, and on a willingness to accept the trade-offs involved in such decisions.

A major weakness of the document is that it fails to acknowledge the urgency of implementing the European Working Time Directive for doctors in training, or the scale of the problem involved in doing so. Although EWTD-compliant models are being developed, their potential contribution should not be over-estimated and there will inevitably be some cases in which relocation is the only feasible option.

We are also concerned about the document’s apparent lack of commitment to quality and reliance on initiatives which have not been rigorously evaluated. There is no indication that the costs of, or outcomes and risks associated with, implementing the proposed service models have been evaluated. Specifically:

• Providing acute medicine without acute surgery involves a risk of lower quality care and an increase in adverse incidents. Ultimately, it is for the public to decide whether the level of risk is acceptable and is outweighed by the benefits of retaining local services.
• The availability of intermediate care is currently patchy, whilst the implementation of home monitoring technologies is as yet a distant aspiration which could only be achieved through a substantial investment in time and funding.
• The document depends heavily upon the introduction of much enhanced information and communications technology systems which remain largely aspirational at present.
• The ‘generalist consultant’ is a concept worth exploring but is not an opportunity to reduce the length of specialist training. We believe that training must be of an appropriate length and that ‘generalists’ require as much training as ‘specialists’.
• Extending the role of primary care is welcome in principle but recruitment problems, workforce shortages and excess workload may make it difficult in practice. The concept of GPSIs is still highly experimental and more consideration will need to be given to the training and assessment requirements associated with these schemes.
• Similarly, we welcome new roles for other healthcare professionals but these will not reduce the need for their existing roles and will not offer any quick and inexpensive solutions.

Introduction
The view that service rationalisation must encompass closing some services was until recently accepted by government as well as the medical profession. This document reflects a major change in government policy direction, driven by political concerns rather than solid evidence, and appears to imply that maintaining local services must now take higher priority than ensuring quality. However we accept that it is for politicians and the public to set the direction of policy and for the medical profession to work within the constraints of that policy.

The document states that its underlying principles are: shifting the focus from relocation to redesign, from individual hospitals to whole systems, and from designing for local people to designing with them. These are sound and valid principles which we welcome wholeheartedly. The NHS belongs to the public, and the wishes of the public must be at the heart of any decisions about service reconfiguration. However, political and public decisions must be based on adequate information about their consequences and wider implications, on an understanding that resource constraints will always place limitations on the service that can be provided, and on a willingness to accept the trade-offs involved in such decisions.

Less explicitly but more urgently, the aim of the document is to resolve the tensions between centralising and localising forces. Implementation of the European Working Time Directive (EWTD) for doctors in training is perhaps the most unavoidable centralising force, and the document fails to acknowledge the urgency of doing so or the scale of the problem involved. The need for specialist services, organisational efficiency and other workforce issues such as working hours for senior hospital doctors are also influential. Although the document plays down the link between volume and outcome, this link is well established in some services, such as paediatric and neonatal intensive care, and paediatric surgery. All of these factors need to be balanced against the high political costs of closing small hospitals against local wishes, and this is a difficult balance to strike.

We fully accept that many services can be provided locally, to a high standard of care, using new ways of working, effective skill mix and technological advances. We also appreciate that these developments may in the longer term make an even greater contribution to sustaining locally-based service provision. However, many of the developments alluded to in this document are still at the pilot stage in which they raise as many problems as they resolve – they do not, in themselves, justify the government’s sudden conversion to a policy of keeping services local. These developments should not be seen as quick-fix solutions – their implementation will require substantial financial investment and long term commitment. For the foreseeable future, providing a high quality service is likely to remain inherently more challenging on a large number of small sites than on a small number of large sites. In the short- to medium-term, this policy will inevitably involve trade-offs in which the quality of care provided, the risk of adverse incidents and the practical implications for workforce and training must be balanced against the arguments in favour of sustaining local services.

It is disturbing to note that the commitment to quality evident in previous government publications appears to have weakened. In recent years, NHS clinicians have made considerable efforts to pursue the quality agenda. Underpinning these efforts has been clinical governance, which enshrines the importance of using the best available evidence when suggesting options for patient management. This document contains a wide range of suggestions for radical change in the way services have been delivered, few of which have been rigorously evaluated and proven to be welcome, practical and cost-effective. If these suggestions were implemented wholesale, it would be impossible to unpick the effects of the various initiatives and thus to evaluate them and to manage the change effectively.