Sir Ara’s grand design

James Gubb, 12 July 2007

Just as you think some kind of consensus has emerged to let things be in the NHS for the moment, another bombshell comes along. ‘Localise where possible, centralise where necessary’, runs the catchy slogan to the latest reform package aimed at the NHS. The report, undertaken by Sir Ara Darzi, the new junior health minister, looks at the state of healthcare in London recommends what can only be described as a dizzying array of service transformations for the capital. But this one, if properly interpreted, isn’t all bad.

The centrepiece of this package is the ‘polyclinic’, of which Sir Ara wants at least five up and running by the end of 2009; ultimately there could be as many as 150. These centres will develop by combining multiple GP practices on one site, and will provide all services traditionally provided by GP surgeries, but also access to ante-natal and post-natal care, healthy living information and services, community care, social care, and specialist advice, as well as diagnostics, low-level urgent care, outpatient appointments and even minor surgery. Increasingly the traditional GP surgery would be wiped out, as would a lot of the capacity of local hospitals, which would largely be responsible for less serious A&E matters and the more routine inpatient care. Serious acute care would be handled by specialised hospitals dedicated to that condition (rather than in hospitals trying to do everything) and most high-throughput surgery would be provided in elective centres – equivalent to the current NHS Treatment Centres and ISTCs.
Few can argue with the premise of Sir Ara’s argument – that all is not well with the NHS in London. According to IPSOS Mori, 27% of Londoners are dissatisfied with the service compared with 18% nationally. The system is inequitable: more is actually spent on patients in boroughs where need is the least; PCTs with the highest QOF (quality) scores are those in the richest areas. And it is, in large parts, grossly inefficient; doctors in a large acute hospital in London typically see 24% less patients than elsewhere in England and in if all London hospitals had achieved the English average for lengths of stay, they would have saved 800,000 bed days or £200m. London also has by far and away the highest rates of A&E admissions in the country and 65% of doctors report problems of care not being adequately coordinated.
There’s not necessarily too much to really take issue with either in the five common principles his working group set out as their guiding lights. Services focused on individual need and choice is number one; the others are the importance of integrated care, that prevention is better than care, a focus on health inequalities and the maxim ‘localise where possible, centralise where necessary’. The latter is the only one that rings alarm bells – centralisation, and the micromanagement that goes with it, has wrecked havoc in the NHS in recent years. But Sir Ara seems to use it in the sense of removing care from the level closest to the patient – i.e. to his specialist hospitals, rather than structural centralisation.
And neither are his conclusions that bad. The rationale for specialist hospitals to treat patients with cancer, heart attacks, serious trauma, and emergency stroke care is sound. A detailed review of stroke services by the Royal College of Physicians found dedicated, high-quality, specialist stroke units saved lives. There is also much international evidence. The Texas Heart Institute provides both better health outcomes (survival rates are 10% higher than the US average) and for much less cost ($27,000 as apposed to $48,000). Much of the superior performance of the French in cancer care is down to the work done by 20 specialist cancer hospitals. This all makes sense. As the report details: specialist teams need enough volume and variety of a medical condition to create a centre of excellence and, above all, technology is driving centralisation of specialist services. ‘The day of the district general hospital seeking to provide all services to a high enough standard are over’, says Sir Ara.
The polyclinic idea is more controversial. On one level it seems like the perfect solution. Economies of scale would suggest that it is much more efficient to have larger concentrations of GP surgeries than many individual practices. Indeed a BMA survey cited by the report found that almost 60% of London GP practices felt their premises were not even suitable for their present needs. It would also seem like a great way to ensure integrated care pathways – by having much of it under one roof and forcing a real crossover between primary and secondary care (both in terms of services and staff). Polyclinics also serve as a local setting, with more of the care pathway closer to the patient and, with a bit of luck, healthcare more tailored to patient need. For all this, Sir Ara also claims that the polyclinic model could save the NHS £1.5bn – largely because they are able to provide services more cheaply than under the existing tariff. (Though he does, somehow, claim that no local hospitals would be closed as a result of this revolution – which surely cannot be the case without massive inefficiency.)
The polyclinic to local hospital/elective care/specialist hospital route could also help the NHS to use competition drive up standards, according to Porter and Teisberg’s seminal study ‘Redefining Healthcare’. This argues that for competition to be effective it must be focused on value, rather than on (for example) activity, which tends to just encourage cost-shifting. Increasingly, they argue, healthcare should be aligned around care pathways for a particular disease/condition, hospitals will increasingly specialise, and PCTs should be able to measure value across the complete pathway to commission effectively.
So all is great, right? Well, not quite. As Nick Bosanquet writes in an open letter to Sir Ara: ‘The report is an enticing vision that might be relevant if we were starting with a clean sheet of paper’. For a start, he quite rightly takes issue with the financial estimates the report provides – to say polyclinics could save the NHS £1.5bn without supporting estimates of income and expenditure, and without any real examples of polyclinics’ performance even internationally, is surely folly.
But the real issue is how any service transformation is to take place. Despite presenting evidence of the effectiveness of patient choice and going so far as to say ‘the choices that patients make about their healthcare will increasingly drive change and improvement in the system’, the report, overall only pays lip-service to patient choice and the role of competition. It instead tends to read as though it is the role of NHS London to impose change. But the fact is that competition is already driving the most adept providers, for example, Guy’s and St. Thomas’, UCLH, and Heart of England Foundation Trusts to specialise. UCLH does not try to provide everything now, but rather try to do a few things incredibly well: heart conditions, obstetrics, tropical diseases, neurology/neurosurgery and homeopathy in particular. And GP practices are already taking advantage of incentives provided under the QOF and new GP contracts to provide other services. For example, the recently opened Heart of Hounslow Centre for Health includes – on top of three GP practices – a range of community care services including improved outpatient facilities, social care outreach, services for children and care for people with learning disabilities, as well as a health information centre and new therapy gym to aid rehabilitation.
Yes, of course, ‘sophisticated commissioners are needed to encourage the development of providers’ (in both primary and secondary care), but the danger is that Sir Ara’s report will cause either the government or NHS London to ignore the market incentives that have been put in place in the NHS – however haphazardly or half-heartedly – by commissioning, payment-by-results and a more liberalised supply side and try to plant his vision on it. Recent experience teaches us this would be disastrous. Instead, this report should be used as a tool that provides some useful incites as to where things could (and in the case of secondary care probably should) go. As Niall Dickson writes in the Guardian: ‘local commissioners have to work out their strategic plans, based on clinical evidence’. I would add patient need and expectations to this, but point remains: to the government and SHAs, keep your hands off!