Public consultation on the Darzi review of healthcare in London has just ended, after a long period of consultation...
Progress in the NHS: it's up to us
WORKERS, APR 2008 ISSUE
Last July, amid a fanfare of publicity in the trade press, and even some national news coverage, Professor Sir Ara Darzi became a well known name. It was he who had been commissioned by NHS London (the capital's Strategic Health Authority) to undertake a review into the health service in London, looking at all of the different clinical specialities, the services delivered and the settings in which they're undertaken, and was charged with the task of proposing recommendations for their improvement.
The overall project was given the title "Healthcare for London, a Framework for Action". The 136-page document was launched on 11 July 2007. In fact, it had actually been launched the preceding week at a meeting with trade unions, all part of a consultation process which has been presented as inclusive from its inception.
Clinicians were involved in drawing up the original document, and indeed Darzi himself makes much of the fact that he is a practising surgeon – and that the consultation is open to all to influence has been much emphasised. The public consultation ended on 7 March, so the review can now be reviewed.
The Baghdad-born Armenian Ara Darzi is now Baron Lord Darzi of Denham and a government health minister in the Lords. He has been charged with developing a consistent method of review of the NHS across Britain. From the beginning it was clear that the London review would form a blueprint for what was to happen nationally, as in so many areas of life.
The review itself looked at seven specific areas of healthcare provision: Maternity and Newborn Care, Staying Healthy (Public Health), Mental Health, Acute Care, Planned Care, Long Term Conditions and End of Life Care.
Elaborate structure
An elaborate structure was set up to drive the public consultation, with a London commissioning group established with 11 primary care trust chief executives overseeing the development of work in each of these work areas, together with some newly added ones: Unscheduled Care, Diabetes and Major Trauma and Stroke Care.
Many changes have taken place over the years within the NHS in London, and throughout the country, which need consolidating. There is a myth among the public that if you are unfortunate enough to have, let's say, a stroke, then the ambulance that comes to get you will take you to the nearest hospital. In London this is certainly not the case.
The London Ambulance Service, more directly influenced by its workforce and trade unions than any other part of the health service anywhere in Britain, will take you to the hospital best able to deal with the specific health problem you have, in this case a stroke (or brain attack, in modern NHS slang). In doing this it may well bypass one, two or even more hospitals en route to the hospital best equipped to deal with your condition. What Healthcare for London seeks to do is consolidate these working arrangements into permanent organisational forms (or as permanent as the NHS ever becomes).
In many areas this will be problematic. At present 31 hospitals provide stroke care in the capital and the number of specialist centres is fewer than 10. So the plan to concentrate resources by concentrating facilities in a smaller number – 7? 9? The final number isn't yet decided – is difficult for many to stomach.
Major trauma: only one centre in London that can deal with the full range of conditions Instead of having a full range of services available at every district hospital, it will mean that stroke centres will be concentrated in far fewer places but should have a much greater capacity to deal with the complex problems involved in strokes. This will mean for instance that the doctors and skilled health workers concerned in delivering stroke care may well be relocated from hospitals where they currently work into these new specialist centres.
This will be a difficult process for those involved. The question workers must assess is how to balance the greater good for workers across the capital in providing the best possible health care with inconvenience and worse for those who have to move or suffer. The job of the unions is to strike that balance.
Major Trauma is another area currently being worked on. There is only one major trauma centre in the whole of London capable of dealing with the full range of health conditions generalised under that heading. This is Barts and the London Hospital at its Whitechapel site, where the Helicopter Emergency Medical Service (HEMS, part of the London Ambulance Service) takes patients.
This is clearly unacceptable for the biggest city in Europe. Many smaller cities have far more trauma receiving centres. So the review was used to propose additional trauma centres – one, two or even three.
Securing approval and resources for this expansion will be extremely important for Londoners and those who work in London. There are currently over 2,500 deaths due to injury in London each year and upwards of 2,000 admissions to an intensive care unit. The professionals in the field estimate that 400 lives could be saved and 1,600 severe disabilities prevented annually by having what would effectively be regional trauma care, spread across centres in London, rather than relying on the existing Whitechapel site.
Recent research has also shown that considerably more people die when transferred to a trauma centre from a local hospital where they may have received initial treatment, than those taken direct to a specialised trauma centre.
The existing facility at Whitechapel manages over 950 trauma patients per year, and in 2006 this service had a 28% reduction in mortality in the most severely injured patients when compared to the national average.
It is most likely that the outcome of the consultation will propose an additional two trauma centres and this is to be welcomed. Yet some ideological opponents of the overall process, including political activists and even general practitioners, constantly ignore the proposals on trauma.
Perhaps the area where there has been greatest debate and controversy is the establishment of so-called "polyclinics". This is the proposal to bring together primary care provision, including general practices, in a single building, although collections of buildings could still be identified as polyclinics.
Several models are being developed, from newly built specialised facilities to "Hub and Spoke" facilities where outlying practices can be connected to a single polyclinic centre, and ranging also to include a provision of polyclinic facilities within a major acute hospital. Already University College London Hospital has put in a bid to run such a polyclinic.
Why is there such hostility to this idea? Some opposition is based on the notion that the working week will be increased from 37.5 to 40 hours. This is a figure buried away in Darzi's technical paper and which certainly does need clarification. But the idea that such a figure will automatically mean those on the standard NHS week of 37.5 hours will immediately have 2.5 hours added to their working week without reference to trade unions is ignorant or malicious; or possibly both.
The other source of opposition is from the GPs, who as self-employed private business people wish to determine themselves how GP practices are organised. Anyone who has tried to help workers employed in general practices to organise knows that some of these are among the hardest-nosed of private employers, and their gathering together in the GP committee at the BMA inevitably fosters their opposition to polyclinics.
It should be no surprise that the polyclinic idea – one of the innovative features of the first Soviet Five Year Plan – has taken 80 years to reach Britain. That it should be opposed by so many should be.
The trauma centres and polyclinics highlight the difficulties in looking at how to make progress in Britain. We are so used to all change being negative that when change, partly driven by organised labour, is proposed, everyone throws up their hands in horror.
Senior doctors are as much workers as the "lowest" porter. So when those doctors propose that clinical care be reorganised they should be listened to. It is naïve to assume that everything will be sweetness and light, and the trade unions, led by Unison, are certainly not doing that.
Of course there is a threat of privatisation – the polyclinics will be ripe for American capitalist healthcare providers. But those very healthcare providers are already buying up general practices.
United Health Europe, owned by the American corporation of the same name and run by Blair's former advisor Simon Stevens and former BMJ Editor Richard Smith, has already won a contract in Derbyshire (which despite the much touted judicial review is showing evidence of actually providing a better service than the previous practice) and is pitching for a contract in Camden, north London.
So the existing GP structure is no defence against US-led privatisation. The answer has to be a clear political one – that the use of private capital in the form of PFI or direct outsourcing to private providers is not acceptable to workers in the NHS or to Londoners.
It has been said that Darzi is in favour of privatisation. It is true that Brown is. But we will not destroy privatisation nor capitalism by opposing polyclinics (or by supporting them, for that matter). Does their establishment weaken us or strengthen us?
Aspirations for improvement
Improved, more centralised primary care has long been an aspiration of organised workers – and was included in the original proposals for the NHS, only to be removed because of opposition from family doctors. That they have been brought forward – at the instigation of people working in the NHS – before we have removed capitalism is no reason to oppose them.
The whole process around Healthcare for London has shown an interesting, and worrying, political truth. As organised workers we have become so used to opposition that we can't spot something we should support. We are so paralysed by threats, in this case threats of privatisation and closure of services, that we can't see where best practice ought to be developed, thereby saving lives.
Had workers and the trade unions in the London Ambulance Service 15 years ago not fought off Thatcher's proposal to completely eliminate what was then, and was for many years, the only London-wide NHS body, then this progress would not be possible.
The proposals for progress are based on the platform of the united, class- conscious and well developed London Ambulance Service, and from that platform must be built a united, politically clear and class-conscious National Health Service. That those in government who are proposing this change share none of those objectives should not worry us.
That they may even be bringing forward some of these proposals to worsen health care and place it in foreign hands is something of which we are aware and which we will need to tackle.
If we are serious about rebuilding Britain, then we must be serious about rebuilding the National Health Service. If we are serious about this then we fight tooth and claw to impose the best proposals that Darzi makes – improving stroke care, increasing trauma care, establishing polyclinics – while rejecting dangerous elements such as the use of PFI, LIFT (another privatisation scam) and outsourcing. Improving Britain – that must be our watchword, and by improving healthcare those working in the NHS can make their contribution to that.