Comment / Time to grasp the nettle on reform

Reconfiguration, transformation, new business models, pathway redesign… Call it what you will, there is growing consensus in the healthcare community over the need to deliver services differently. The focus is better care and outcomes. Yet we have failed to get the public engaged in the debate or to understand the motivation.

Three years ago the Academy of Medical Royal Colleges, the HFMA and NHS Confederation issued a statement that said ‘planned service redesign and reconfiguration’ would have a part to play in meeting the service’s challenges. The process had to be evidence-based, involve clinicians and the public. But if managed well, ‘appropriate service redesign and reconfiguration can improve patient care’.

The bodies pointed at the success of specialist stroke and trauma services, but said that while the benefits of specialisation were often accepted, the ‘logical consequence’ – that other hospitals would lose services – is then ‘ignored or refuted’. Yet the reconfiguration of services argument remains hard to sell. The reaction to health economy-wide changes in South London and Mid Staffordshire are evidence of this. I visited a town recently where the local hospital was under ‘threat’ of significant service rationalisation. Their campaign headquarters in the shopping precinct encouraged the public to support their plea to ‘save our services, save our hospital’. Nothing you will notice about ‘improve our outcomes’!

The problem is that we have started the debate with the solution – that centralisation of the more complex, less common diagnoses and procedures will generate better outcomes – and we just expect the public to understand the concept. In times of austerity, such changes are viewed with suspicion and seen as cost-cutting exercises that remove valued services from the local population. 

Cost, value and sustainability are completely valid considerations in any decisions about changed service provision. But we need to get the debate firmly focused on the principal drivers for rationalisation because, in this case, cost reduction is a side issue. The main driver is that doctor training has changed. Less training time means doctors specialise sooner and concentrate on sub-specialisations, as this has demonstrated improved outcomes. It is not realistic to have all sub-specialty skills in every hospital. Doctors need to see the right volumes of patients to maintain and improve their skills, and there is clear evidence linking a critical mass of patients with improved outcomes.

Technology is another driver. Best outcomes are supported by the availability of 24/7 access to diagnosis and, in some cases, treatment technology. Realistically, this needs to be provided in designated centres. There are cost implications in having this technology in all hospitals, but the major limitation would be having the expertise and experience to interpret the data and act on it.

I am not describing the end of the district general hospital. We need to redefine DGHs for the 21st century. The opportunities are considerable. Darzi-esque super-health facilities providing ambulatory care linked by telemedicine to major centres; diagnostic services and inpatient care for a specified range of services – all are possible. We could see the co-location of GP urgent and out-of-hours services, triaging patients before escalation to a hospital emergency service staffed by consultants. How good would that be for patients?

The public has always been protective of local facilities, but we have a chance to switch the focus to services and outcomes rather than bricks and mortar. NHS medical director Sir Bruce Keogh has put reconfiguration firmly in the public eye with his announcement on urgent care services. And discussion on seven-day services provides another chance to engage with the public. Transformation of services is about delivering better care and we need to grasp the nettle and take the debate to the people.

Chris Calkin is chair of the HFMA Policy Forum