Tackling Vested Interests in the NHS

If the public knew how self-serving some elements of the NHS were they would have a great deal more sympathy for the government's efforts to reform the service.

The debate over NHS reform was being framed by vested interests in the NHS; principally the royal colleges and trade unions. That has improved in recent weeks, with more plain English and examples of positive patient experience being used to describe the difference the Health & Social Care Bill will make. As the bill becomes law we need to build on this momentum.

Governments and health experts have made the case for care being devolved from acute trusts to the community for decades. There has also been agreement that a more holistic approach to healthcare, including the integration of health and social care, benefits both patients and the bottom line. Yet there has been very little improvement on either front.

Last week I met managers and clinicians working in the NHS. One, who was a board member of our local clinical commissioning group, made an important point. She complained that it was terribly difficult to wrest services from the local acute hospital; in fact, she likened it to entering a war zone. I argued that the Bill was enabling her to do just that; without the direction enshrined in the bill she'd have much more of a struggle.

Clinical commissioning groups need to be strengthened in this respect. Following the listening exercise however, the government was obliged to amend the bill to include secondary care doctors on clinical commissioning group boards. We must make sure their inclusion does not inhibit the transfer of services from hospitals to the community.

If the public knew how self-serving some elements of the NHS were they would have a great deal more sympathy for the government's efforts to reform the service. It is not just the transfer of services from hospital to the community. Just as serious are the impediments to changing the way services are delivered within the secondary care sector.

The politics of service re-configurations are appalling. In the Black Country, as in many other parts of the country, the re-organisation of vascular surgery and stroke care is on the agenda.

The consultation was protracted and in two stages: first the organisation of vascular surgery, to be followed at a later date by stroke services. When, finally, the outcome of the first stage was agreed, the hospital which won the contract to be the vascular surgery hub was not the one expected to do so. Now they are finding the hospital which expected to win doing all in their power to neuter the implementation.

Importantly it is the centralising of stroke services across a population of some 800,000, making the provision of a 24/7 service economically viable, that is the cornerstone of what will save the lives of stroke sufferers. Yet incredibly some clinicians in the acute hospitals have been warning against any centralisation of stroke services.

It is salutary that some clinicians working in the NHS, consultants so respected by the public, will prevent life saving change in order to defend working practices that are outdated, outmoded and cost lives. The public would be outraged if they knew the half of what goes on in the clinical management of the NHS.

A young, newly qualified physiotherapist came to my surgery a few weeks ago. She had some part time work but was struggling to find a full time position. There is much evidence that physical activity improves depression, and she wanted to offer physiotherapy and fitness classes for patients with mild to moderate depression.

This encounter reinforced the need to devolve commissioning down to primary care level, enabling innovative commissioning within the community. Under the PCT in our area general practice was stifled and reliance on expensive secondary was always the default position. Through the bill the scope will exist for commissioners to include physiotherapy and fitness classes, even yoga classes, as part of the pathway of care for depressed patients.

The change made possible by the bill challenges the 'medical model' of healthcare provision, which has its roots in several centuries of western medicine. This model underpins the pre-eminence of the medical profession in the delivery of healthcare, downgrades the practitioners of 'complementary treatments', and absolves the patient from any responsibility in the process. The medical model needs to be challenged.

It is difficult for complementary practitioners to amass the evidence for the effect of their interventions. By and large their work cannot be patented so there is no incentive for the pharmaceutical industry to fund clinical studies. Nonetheless, evidence is emerging for the benefits of, for example: physiotherapy, podiatry, acupuncture and speech and language therapy.

Unfortunately, these disciplines are seen as secondary for the health service in a cash-constrained environment. Yet the treatments and interventions of these non medical professionals almost always drive costs down and improve the quality of the patient experience.

For the patient to feel the positive effect of these reforms there must be a substantial re-allocation of resources out of hospital and into the community. The Bill provides the framework for this to happen through primary care commissioning, the integration of health and social care and the facilitating of other providers that can offer more holistic treatments as part of the care pathway.

These other providers need over time to be on a level playing field with the NHS however. At the moment they are disadvantaged in the contracting process by employment regulations when it comes to taking on NHS staff; and VAT liabilities for which the NHS are not liable.

The bill transfers public health budgets to local authorities, merges health and social care, and establishes health and wellbeing boards to champion patients and hold clinical commissioning groups to account. These developments, combined, could produce the radical shift from hospital to community so badly needed in our NHS.

GPs, nurses and patients need now to combine forces and ensure that the resistance to change they will encounter does not limit the improvements in care that are made possible by the Bill.


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