The response of the British Medical Association to Lord Darzi’s review 'Healthcare for London: A Framework for Action'
September 2007
1. Introduction
The British Medical Association (BMA) would like to take this opportunity to respond to Lord Darzi’s review ‘Healthcare for London: a framework for action’ and to outline the views of its members. The BMA is an independent trade union and voluntary professional association which represents doctors from all branches of medicine in the UK.
Our response includes input from all the BMA committees representing major branches of medical practice, as well as the community care committee and patient liaison group.
The Association recognises that, in the interest of patient care, there is certainly a case for changing how some services are provided in London over the next ten years. In some circumstances this may involve moving additional services into the community, or introducing greater centralisation of more complex care. We believe, however, that the nature of service provision should depend on, and be led by, the local needs of the individual London borough. The distinctive educational, training and research role of medicine in London should also to be fully considered. Whilst we welcome evidence-based service reconfigurations that are clinically appropriate and enhance patient care, we have severe reservations that the proposals detailed in the review do not build on the best aspects of the NHS, but have the potential to introduce damaging fragmentation to the service.
We agree that workforce, buildings and tax-payers’ money need to be used more effectively, but this will only happen if policy is coherent and is left for long enough in order to be properly and fully implemented. The proposals detailed in the review would require a considerable ‘up front’ investment and we fail to see how they would demonstrate to be a cost-effective use of NHS funding. Commitment to invest in the right type and amount of resources, including finances, staff and premises, are needed to achieve change of this scale and we have serious doubts over whether such investment would be seen. To date, no development of the NHS has been accompanied by such support.
2. Community-based care
2.1 Enhancing community facilities
The need to provide a new kind of community-based care at a level that falls between the current GP practice and the traditional district general hospital is a major theme detailed in the report. The report fails to recognise, however, that there are already numerous community hospitals providing a variety of largely intermediate care services, a number of specialised primary care services delivered by GP practices and/or GPs with special interest as well as a range of consultant-led community health services that have their own facilities, including community health services, speech and language services and family planning services. The BMA supports the principle of care being provided ‘closer to home’, provided it is clinically appropriate and where these new services will genuinely offer a cost-effective option. However, we believe that this should be achieved through building on the current models that are working well, rather than through the introduction of new infrastructures which have the potential to fragment the local health economy. The proposals in the report highlight opportunities for cooperation and collaboration between GPs and consultants and this should be encouraged through new ways of working.
It is our view that, with further investment, community facilities could be built upon and enabled to extend the services they provide. This would avoid the need to develop polyclinics which will not be an effective solution in most circumstances. These developed facilities could also provide effective links with social services, employment advisors and a range of other clinical services, whilst preserving GP practice-based care for the majority of patients’ needs. The best of the current community-based facilities have thrived when they have been led by local clinicians, with strong collaborative working between primary and secondary care. Services cannot be developed without local clinicians taking the lead and identifying the priority services for their local communities. In addition, any proposed service changes must involve the local Directors of Public Health.
It is our view that in some circumstances, more procedures and diagnostics could be provided in the community, provided these services are identified and agreed locally. There is, for example, an over representation of admissions in London for patients with acute psychotic episodes and a greater emphasis on community provision is needed. However, to be most efficient, as judged by clinical and cost criteria, other specialist services will clearly need to remain in the multidisciplinary hospital setting. Services provided in the community need to be utilised to capacity in order to be cost effective and must therefore be restricted to high-volume services only. As well as being underused, low volume services provided in the community result in a lack of flexibility in appointment times, as the low demand limits how frequently the service can be provided at the community location. Therefore whilst patients gain in the convenience of the location, there is a loss of convenience in the frequency and availability of appointments. It must be recognised that sufficient workload is necessary to make effective and efficient use of consultant and specialist time, including time spent travelling to various different locations. This is a major problem for consultants currently working in outreach clinics. Any community facility should run at similar efficiencies to those of local hospitals.
Any diagnostics carried out in the community would need to be undertaken by those with the appropriate skills to interpret the results, or under their direction. We firmly believe that a large portion of hospital services that are moved into the community will still need to be provided by those consultants and specialists currently providing the services. In addition, the facilities that are used to provide community services must support the services being provided by consultants, such that their work is not limited by the available resources. There will be implications for the quality of service provided in the community where, for example, the back-up services normally available to a consultant are not present in the community. Clearly complex diagnostics and new developments will continue to require more central hospital facilities. It should be remembered however that, in the interest of delivering care closer to patients home, many people live near to their local hospital and this convenience is valued by patients.
The review states that ‘nurses and GPs could carry out a large portion of the outpatient follow-up appointments currently happening in hospitals’. Whilst some follow-up appointments could be carried out by nurses and GPs, this would need to be judged on a case-by-case basis depending on clinical requirement and would vary according to specialty. Moving care closer to home should not inappropriately reduce access to a specialist medical opinion and patients should still have the opportunity to discuss future care with their specialist where necessary. In addition, it is in the completion of the patient journey and episode of care, particularly after surgery, that the outcome of invasive procedures may be assessed and is important for audit, training and teaching. Education, training and research must not be adversely affected by a move of services out of hospitals into the community.
Clinical engagement is imperative to ensure that only the most clinically appropriate care is moved into the community and that changes in services provision do not result in deskilling of existing staff or redundancies at the original provider. With activity being transferred to a community facility, the impact of the cut services on the local hospital must be considered and must not reduce the quality of care delivered in either setting. We are concerned that the loss of income resulting from the loss of activity could be detrimental to the stability of the Trust, unless it receives sufficient volumes of ‘less complex’ work from more centralised hospitals.
We believe that the following factors should be considered in assessing whether it is appropriate for any specialist service to be moved out of hospitals:
- What improvements will there be to patient care?
- What back-up services are required and can they be efficiently and safely provided in the new setting?
- Will there be sufficient workload to make effective and efficient use of consultant and specialist time?
- What impact will the move have on regional and super-specialist services, and other services that continue to be provided in a hospital setting and primary care facilities?
- Do the changes fit in with the plans of local practice based commissioners?
- What impact will the changes have on education, teaching and research activities?
The report suggests that moving care out of hospitals and into the community will result in cost savings. However, although there is a general expectation that community care will be cheaper than hospitals care, research suggests that this expectation is not always met. Indeed, although there may be savings on reduced outpatient attendance, additional costs of community care need to be fully considered, such as service-led increases in demand and the loss in economies of scale. Within the evidence available on this issue, a number of varying and conflicting conclusions have been drawn and so whether or not moving care out of hospitals will actually reduce costs will depend heavily on the specific arrangements of the new service.
2.2 Polyclinics
We support the concept of GPs working together in larger groups and practices and providing a wider range of services where the clinicians concerned believe it is in the best interest of their patients. Coercing services into polyclinics, however, is not the way forward. The review gives no consideration to how polyclinics would be run or the contractual status of either GPs or consultants working within them. Indeed, it is unclear whether the clinics would be staffed by doctors employed by NHS Trusts or private organisations holding APMS or other such contracts.
If clinics were staffed by private organisations holding APMS contracts, this would result in the widespread replacement of the independent contractor model of general practice with a salaried or locum model, akin to that of existing PCTMS practices where the turnover of employed doctors is often high. If such a model is favoured by the Department of Health, there appears to be a lack of recognition of the value and strengths of the independent contractor model for general practice, based on the registered list, and how it offers patients holistic and continuity of care, a personal doctor and an independent health advocate within the healthcare system. A survey of 10,000 patients has shown that nine out of 10 people thought it important to be treated by a doctor who knew them and their family history and 89 per cent said it was important to be looked after by the same GP. A report by the Royal College of General Practitioners cites continuity of care as ‘… an essential element of modern general practice and … a pre-requisite for high-quality consultations and effective management. There is also evidence that personal continuity, as opposed to organisational continuity, is associated with greater patient satisfaction with care and more efficient use of resources’. Similarly the National Primary Care and Development Centres has reported that ‘…patients more than anything else value a high standard of inter-personal care… it is important to ensure that this key attribute of primary care is not lost among attempts to improve more readily measured aspects of care.’ General practice is highly valued by the population and GPs must continue as the key gateway to the NHS. We would strongly challenge any move towards the majority of doctors not having the option of remaining as independent contractors.
The review emphasises that more care should be delivered both in and nearer to patients’ homes. However, the proposal to introduce polyclinics is contrary to this as, for the majority of London’s population, a polyclinic would actually be further away than their existing local GP surgery. We firmly believe that developing the current model of general practice will provide the most cost effective and efficient opportunity for patients to be treated close to their home. Greater investment in general practice is needed to enable the expansion and provision of a greater range of services, rather than the imposition of costly polyclinic infrastructures. NHS Estate strategy needs to be examined and many of the disadvantages of PFI and LIFT recognised. We recommend the restoration of support for primary care contractors to commit themselves to investment in premises for the provision of medical services and the development of PBC.
The report fails to acknowledge that the proposals would have a vast impact on the current working hours of doctors, as more services would be provided round the clock and non-urgent GP services extended to include weekends and hours outside the presently defined contracted working hours (Monday to Friday 8.00am to 6.30pm). The English Department of Health’s GP Patient Survey showed 84 in every 100 patients to be satisfied with the current opening hours in their practice. Only four out of every hundred patients wanted practices to open on a weekday evening and seven out of every hundred on weekends. Given that only a relatively small minority of patients actually want to see an extension of ‘routine’ GP care, we would challenge the view that this is a good use of scarce NHS resources. Another reason we would strongly oppose the concept of ‘routine’ GP care being provided outside of these defined hours is that it would be likely to have an impact upon the quality of routine care ‘in-hours’ and the implication that this would become a 24 hours a day, seven days a week service. Such arrangements have never existed in the NHS and the resource implications are considerable. Furthermore, the proposal conflicts with the imperative to manage demand and would lead to a situation where the demands of the articulate are met at the expense of those in clinical need.
3. Local hospitals
It is our view that local hospitals should provide the majority of inpatient care, but we have concerns about the proposals for emergency care services. We believe that accident and emergency departments must retain 24 hour emergency surgery facilities and that night cover by a major acute hospital is not clinically acceptable, as critical time would be spent on transferring patients. Fully functioning hospitals must be properly supported with fully functioning emergency surgery. Providing acute medicine without acute surgery involves a risk of lower quality care and an increase in adverse incidents. The review fails to make a case for why some hospitals should be able to provide 24 hour emergency medical, but not surgical, care. In addition, the provision of only level 2 critical care within local hospitals would lead to unnecessary inter-hospital transfers.
Whilst we recognise that the centralisation of some services enhances clinical outcomes, this is not the case for all conditions. A recent report demonstrated that increased journey distance to hospital is associated with increased risk of mortality . The risk of mortality significantly increased in patients with respiratory problems, but was less significant for patients in other clinical categories, such as those with chest pain. Indeed there is evidence that for some groups of emergency patients, care provided in specialist centres improves outcomes. Examples include primary angioplasty for acute myocardial infarction and care for major trauma patients with injuries . For these groups of patients, the benefits of specialist centred care would outweigh any detriments resulting from the increased travel distances to the centres. For other critically ill patients, however, such as those in anaphylactic shock, choking, or having acute asthma attacks there may be a detriment in having to travel increased distances. It is likely that these patients would survive by travelling a short distance to a local A&E department rather than travelling a long distance to a specialist hospital. Therefore, although it may be beneficial for some patient conditions to bypass local hospitals to specialist centres, local A&E departments should not be downgraded in the process. Any such downgrading would force patients to bypass their local hospital, including numerous patients who would benefit from the services.
We believe that the introduction of telemedicine for intensive care would have a detrimental effect on outcomes, given that critical care is a ‘hands-on’ skill and requires a multidisciplinary team approach, both of which telemedicine would not be able to provide. The use of telemedicine in certain international settings has resulted out of necessity where vast distances are involved, and is not appropriate for London.
4. Urgent care centres
At present patients do not feel well informed about how to access treatment out of hours. Services need to be more clearly integrated and patients given better information to guide them to appropriate advice. The report does not acknowledge the importance of educating the public about where they can receive out of hours treatment, as this alone would help to significantly reduce inappropriate admissions to A&E. It is not apparent from the review what the difference between urgent care centres in hospitals and those in polyclinics would be and the reasoning for the two locations. We would recommend that urgent care centres were only located at the local hospital, as a ‘front door’ to A&E departments. Urgent care centres used in this capacity could provide GP out-of-hours services and patients could be directed to A&E if emergency care was needed; thus reducing unnecessary hospital admissions.
The widespread introduction of urgent care centres, accessible by patients both in hours and out of hours, has the potential to sideline GP practices from the delivery of urgent care. We believe that the non-involvement of a GP practice in the urgent care of a registered patient would inevitably be detrimental to that patient as not only does using the knowledge of the patient history and medical record held at GP and primary health care team-level help to avoid inappropriate hospital admissions, but the coordination of patient care at this level will lead to the best possible health outcomes. In addition to the impact this would have on patient care, removing the urgent care element from general practice will lead to the traditional ‘gatekeeper’ role being lost, which in turn could lead to an increased demand on healthcare services. Furthermore, the proposals require significant advances in information technology and an increased use of electronic data in order to allow continuity of care between providers, which remains largely aspirational at present.
We do not believe that a single urgent care phone service would help ensure that patients were treated in the most appropriate environment, as the public would almost certainly continue to look to their GP practice as a first point of contact for urgent assessment. The BMA’s Patient Liaison Group agrees that existing problems regarding patients understanding of how to access the most appropriate care would be exacerbated by removing their GP practice as the first point of call.
5. Elective centres
We recognise the potential benefits of improved efficiency in the separation of elective and acute services, but believe that both services should be located at the local hospital. In this way elective centres would have easy access to a wider clinical team and allied specialties and ensure maximum patient safety. Sharing common laboratory and clinical services would also increase efficiency. Consideration also needs to be given to the impact of case selection in elective centres on the training of junior doctors and how training opportunities in these procedures would be covered under these proposals.
We would strongly oppose elective centres (or indeed polyclinic facilities) being provided by the private sector, except where there is no NHS capacity to provide the service. There is no evidence that the private sector offers improved services or better value for money than the NHS. Furthermore, in many areas the need for independent sector treatment centres (ISTCs) to provide extra capacity has been poorly assessed and contracts, paid for regardless of activity, are under-utilised. This is a shameful waste of NHS money. An agenda that favours a continued increase in the role of the private sector in the NHS will inevitably fragment health services, undermine integration and ultimately threaten the quality of care received by patients rather than drive up standards.
6. Centralisation of care
The review proposes that services should be centralised where necessary and includes the expansion of major acute and specialist hospitals. The BMA recognises that a measure of clinically-led reconfiguration of acute services is important to improve patient care, but believes that robust tools are needed to ascertain the optimum clinical configuration of services and the safe minimal levels of service. We therefore support the proposal to centralise care for heart attack, severe trauma and stroke services where there is evidence that centralisation maintains standards. Centres of this nature would clearly need to meet the targets for investigation and treatment within the time parameters and be supported by extensive transport links to maintain patient safety and build expertise. Transport of patients is central to the successful implementation of the proposals in the review and the report fails to give sufficient attention to who will escort patients within the dedicated transport service. As mentioned under section 3, the impact of increased journey distance associated with specialist centres must be considered for all conditions individually. Skilled diagnostics at the point where the patient presents would be needed in order to arrange immediate care and investigation.
Clearly the distribution of acute hospitals, including within outer London, needs to be considered extensively to ensure patient safety. The review fails to acknowledge that major acute and complex care, are not necessarily interchangeable terms. Some acute care is relatively simple and some elective care is extremely complex. Further clarification is therefore needed on the threshold and definition of ‘complex treatment’, in relation to treatment being undertaken in major acute sites. What is important is the matching of trained staff and facilities with case mix, which often requires a minimum critical mass.
It is well recognised that the degree of specialisation required for high quality outcomes cannot be achieved at all existing hospitals. Indeed, it is for this reason that existing local district general hospitals do not provide the range of services that they did in the past. Hospitals should be encouraged to specialise where it is clinically appropriate and part of a planned local provision, underpinned by national clinical standards for quality. In developing specialist hospitals, the handling of co-morbidities must be fully considered and the co-location of services with acute hospitals. In addition, research suggests that critically ill patients are likely to have a high degree of mental health co-morbidity, especially in the elderly . As such, adequate provision for mental health liaison services in specialised hospitals must be taken into account.
It is imperative that where services are centralised, the knock-on effect on the local hospitals are fully considered. For example, consideration must be given to arrangements for ‘backfilling’ the loss of services at the base hospital, and justified resource allocation so that one site does not receive the majority of resources at the detriment of care delivered at other local sites. The location of centralised facilities must also reflect the distribution of London’s population and must therefore not solely be concentration in central, but also Greater London.
As recognised in the report, there would need to be a review of funding flows and Payment by Results, so that funding supports the centralisation of specialist care and the separation of complex and routine care does not result in the complex provider not being fully reimbursed. The issue of funding flows carries a high risk in this area if this work is not completed and properly piloted before any changes to London's acute sectors are made.
We have serious concerns that although the review is currently specific to London, similar plans may be rolled-out to other parts of the country. The population, infrastructure and transport networks differ considerably outside London and as such these proposals would be wholly inappropriate in other, particularly rural, areas. Backing this notion, the report states that ‘the number of specialist hospitals in the US have doubled in the last 20 years and we expect to see a similar trend in England’.
7. Academic health centres
The BMA supports the establishment of the Academic Health Science Centre (AHSC) between St Mary’s NHS Trust, the Hammersmith Hospitals NHS trust and Imperial College. We believe that the strategic integration of service, education and research through unified governance and a single mission across hospital trusts and the university will offer new and unparalleled opportunities to improve patient care through collaboration and innovation to bring out new ideas, evidence and products. To reduce health inequalities, consideration of the benefits offered by the AHSC model and European models for academic-bioscience should be considered in other parts of the UK, not just in London and the South East.
In addition the best use of new configurations of academic-bioscience hospitals, maximising the contribution of academic medicine in the health service will require careful funding, collaboration with key stakeholders and ensuring that research and education are integrated in all healthcare settings. In our opinion, the report misses an opportunity to include the values of education and research in the NHS at the centre of healthcare delivery for London. There is, for example, no reference to medical education or research in primary care despite one of the main messages of the report being to move health services into the community.
Academic input will be excluded from the majority of healthcare delivery if limited only to Academic Health Science Centres that are linked to specialist centres. It should be automatically integrated into other settings such as primary care to ensure that research and education are ‘mainstreamed’ across the delivery of healthcare; access to all patients is vital to clinical research – often healthy patients are needed not only those with multiple pathology who attend specialist centres.
Addressing the financial disadvantages of undertaking a career in academic medicine is also key and there is no mention in the report of the problems associated with the lesser academic salaries for doctors, especially given the high cost of living in London. Nor is there acknowledgement that London trains significant numbers of medical students and the majority of the UK medical academic population all of whom need clinical and academic supervision from an ageing and greatly reduced workforce.
The report does not acknowledge recent destabilisation of medical education budgets nor does it recognise that the PFI system discourages the provision of minimum educational facilities (e.g. teaching space, rooms for students, library facilities) for an increased numbers of medical students and junior doctors because, by definition, such space and facilities are non-profit earning. To enable a fully trained workforce to provide high quality patient care there is a need to define the teaching obligations of all of the settings for healthcare delivery, including primary care.
8. Summary of key points
- In the interest of patient care, there is certainly a case for changing how some services are provided in London over the next ten years. In some circumstances this may involve moving additional services into the community, or introducing greater centralisation of more complex care. However, we have serious reservations that the proposals detailed in the review do not build on the best aspects of the NHS, but have the potential to introduce damaging fragmentation. The proposals would require a considerable up front investment and we fail to see how they would demonstrate to be a cost-effective use of NHS funding.
- The BMA supports care being provided closer to home, provided it is clinically appropriate and genuinely offers a cost-effective option. Services cannot be developed without local clinicians taking the lead, with strong collaborative working between primary and secondary care, and identifying the priority services of their local communities. Extending community services should be developed by building on, and investing in, the current models that are working well, rather than through the introduction of new infrastructures which have the potential to fragment the local health economy.
- Extending services in the community must ensure that: procedures and diagnostics are restricted to high-volume services, to ensure sufficient workload to make effective use of consultant and specialist time; facilities fully support the services being provided; access to a specialist medical opinion is not inappropriately reduced; and the knock-on effect on the local hospital and resource allocation are fully considered.
- We support the concept of GPs working together in larger groups and practices and providing a wider range of services where the clinicians concerned believe it is in the best interest of their patients. Coercing services into polyclinics, however, is not the way forward. Any development of GP practices must ensure: the option for an independent contractor model for general practice is maintained; GPs continue as the key gateway to the NHS; and routine GP care continues to be provided within the existing contracted working hours.
- Local hospitals should provide the majority of inpatient care and accident and emergency departments must ideally retain 24 hour emergency surgery facilities. Providing acute medicine without acute surgery involves a risk of lower quality care and an increase in adverse incidents.
- Urgent care centres should only be co-located at local hospital A&E departments. GP out-of-hours services provided at these centres could direct patients to A&E if appropriate, but would reduce unnecessary hospital admissions. GP practices must continue to deliver urgent care in hours, as patient history and medical records held at GP and primary health care level avoids inappropriate hospital admissions and leads to best possible outcomes. A key to reducing inappropriate admissions to A&E is through educating the public about where they can receive out of hours treatment.
- The separation of elective and acute services has the potential to improve efficiency, but both services should be located at the local hospital site for maximum efficiency and patient safety. We would strongly oppose elective centres, being provided by the private sector, except where there is no NHS capacity to provide the service.
- Hospitals should be encouraged to specialise where it is clinically appropriate and part of a planned local provision, underpinned by national clinical standards for quality. Robust tools are needed to ascertain the optimum clinical reconfiguration of services and the safe minimal levels of service. The handling of co-morbidities, transport links and funding flows must be fully considered to support the centralisation of services.
- We support the establishment of the Academic Health Science Centres, such as that between St Mary’s NHS Trust, the Hammersmith Hospital NHS trust and Imperial College. Consideration of the benefits offered by the AHSC model should be considered in other parts of the UK, not just in London and the South East. There is a need to define the teaching obligations of all the settings for healthcare delivery, including primary care. Academic input will be excluded from the majority of healthcare delivery if it is limited only to AHSCs that are linked to specialist centres.