| A new review of healthcare for London has some interesting suggestions – as well as some questionable premises and serious omissions... |
The future of healthcare for Londoners
WORKERS, SEPT 2007 ISSUE
"A Framework for Action" – Professor Ara Darzi's Healthcare for London Report – was publicly launched on 11 July. Professor Darzi has gone from being an internationally renowned surgeon and clinician to a junior minister in Brown's Health team, with a brief that started out as an independent review of London's health service and broadened to review the rest of England's health care provision.
Each chapter of the Framework has been written by a group of clinicians who have decided what is best for their part of the NHS. This approach has much to recommend it. But now it is essential that the wider NHS workforce, its trade unions and the wider public take charge of the process. Already one fundamental premise of the document is being questioned by both clinicians and patients. On page 7 it states, "The whole thrust of this report is to tackle health inequalities by improving services across London giving everybody access to best possible care."
Yet since Sir Douglas Black produced his report "Inequalities in Health" in 1980 and Margaret Thatcher tried to suppress it, NHS workers and researchers have known that health care services have little impact on health inequalities. Employment (or lack of it) and income are the key determinants of health – and without addressing the widening income gap in London, no amount of health care planning will make any difference. Tackling health inequalities in 2007 involves looking at employment patterns, poor housing and issues such as the role of EU migration on overcrowding and suppression of wage rates in the capital.
New models
The proposed health care delivery models, the new centres of specialist excellence, improved out of hours services, new urgent care centres, new thinking around GP services – polyclinics, proper workforce planning and training, enhancement of skills, plus closer working with the GLA and Mayor's Office, are all to be welcomed and will provide a basis for discussion.
However, effective planning always starts with a good understanding of the current situation. The deficiencies of the current services are well illustrated in the Framework but major obstacles to rational planning are not mentioned, for instance the Private Finance Initiative (PFI). London hospitals and clinics are now peppered with PFIs – inflated mortgages that will need paying for several decades. Services at these locations will need to be commissioned to pay the bills, even if a rational planner might wish to develop services elsewhere. A "framework for action" must address this issue. The Chancellor now turned Prime Minister put us on this path and now needs to be forced off it.
The review takes place against a backdrop of public unease over health reorganisation.
Another detail omitted from the Framework is the number of hospital beds that the capital needs. Of course the way in which a bed is used is also important, and conditions that used to require admission can now be treated as day cases. But a rational planner must have a number in mind and should also be open about the fact that London has fewer hospital beds per head of population than France, Germany or the Netherlands. European countries that have the lower rates of diseases such as MRSA have more single rooms and generally more space between beds. Yet every PFI-built hospital has had fewer beds and less physical space. Any decision that leads to patients being physically crowded and beds being used more intensively is like a decision to build on flood plains.
One section of the document that has puzzled community nurses is about long-term health conditions and maintaining patients in their own homes. They would support this, but at the moment their numbers are being cut as trusts struggle to manage budgets. The Framework suggests, for example, that London will require 570,000 more asthma appointments with specialist nurses – potential ammunition for those currently facing job threats.
More profoundly, many district nursing services across the capital may be privatised in the next twelve months, disrupting their relationship with local authority social services, with which they typically share a boundary at present. Here too the Framework faces two ways. While advocating public sector partnership, it also praises the work of the American company Kaiser Permanente.
The response by district nurses to the current privatisation plan has been generally muted, with some rushing off to set up their own businesses and others hoping to retire earlier than expected. The Framework offers district nursing and other community services a possible lever.
The Framework correctly calls for more workforce planning in London – just at a point where any remaining expertise in this area has recently been made redundant after London's four previous strategic health authorities were merged into one NHS London authority. It assumes there should be centralised planning for London. But processes already in motion such as PFI and Foundation status give individual units more power to dispose of their estates as they wish, fragmenting services. All these processes are antagonistic to the sort of controlled change envisaged. Unless we deal with the political blocks to service development, improvements will not be achieved.
Consultation
This independent report will be tabled at NHS London's Board in August and consultation will commence across London in September. Health trade unions have welcomed the general objectives of the report and hope, jointly through partnership working arrangements with trusts, to look at how service provision, as far as possible, can be provided in a public sector framework. Professor Darzi is on record that this model need not rely on marketisation or private sector provision for delivery, and the challenge for health unions and patients in London is now to work with both commissioning agents and trusts to ensure that any reconfiguration of services remains within the control of the NHS.
The Darzi Report talks of a 10-year strategy to deliver world-class health care provision in London. That's a goal to support – while ensuring it is in the context of public service not marketisation, privatisation or the multinational private health corporations.