The author a senior consultant with the NHS is concerned with the pace and reasoning behind some of the reforms suggested by the Government especially since NHS comes on top on most areas when compared with other health care systems,
As a consultant anaesthetist working in the NHS, I see first-hand the benefits of collaborative working in a multidisciplinary team. In caring for patients the clinical team must first consult with, examine and investigate the patient to reach a diagnosis, then assess treatment options, discuss these with the patient and then deliver care that best meets their individual needs. The skills of many different clinicians and practitioners are involved in each treatment pathway.
One cannot help but feel that the reforms of the NHS would have proceeded more smoothly and effectively had a similar pathway been followed before the Government rushed in to implement its plans: properly ascertain the problems within the NHS, evaluate treatment options, consult widely and finally begin the process of change. This step-wise approach seems more likely to have produced a successful outcome.
Many of the changes have been put in place without evidence to support their introduction - this has resulted in a feeling that some of the changes have been made “on the hoof” which has undermined confidence in them. In addition, some changes introduced relatively early on have later been reversed - most notably changes to health authority structures.
Few would dispute some of the broad policy aims. For example, the drive to reduce waiting times and introduce improvements in efficiency, are laudable aspirations. To help deliver these aims the Department of Health introduced Independent Sector Treatment Centres and private sector run NHS facilities. However, the involvement of the independent and private sectors in these developments was largely untried and lacked a solid evidence base. There is no evidence that these external providers are able to treat patients more efficiently or produce better outcomes. Neither is there evidence that treatment delivered in this way is more cost-effective - such evidence, as is available, suggests the opposite, that NHS hospitals are more cost-effective.
Similarly the desire to upgrade NHS hospitals is a worthy aim. However, the method by which new hospital building has been funded represents questionable value for money for the public purse. The Private Finance Initiative, under whose auspices all major NHS building has taken place in recent years, has long been criticised as too expensive and too generous to its private sector backers - indeed the public accounts committee was particularly strident in its criticism of some PFI projects. All of these policy developments are characterised by the same features: a failure to properly assess the problem, to consider alternatives and to involve staff, the public and, most importantly, patients through real consultation prior to the instigation of change.
The NHS was recently compared with the health care systems of other western nations including the USA, Australia, France, Germany and Canada. The NHS was judged best in terms of equity of access, outcome and cost effectiveness. It is difficult to see the wisdom of changing the NHS to be more akin to the systems which have been evaluated as inferior.
Doctors are not afraid of change - indeed most doctors lead on innovation and change. In common with patients, doctors are also taxpayers and want to see NHS services that are both superbly effective and optimally cost-effective. Doctors want to see change that is based on real and solid evidence - based on the preferences of patients, an analysis of the cost effectiveness of various methods of service provision, or a review of treatment outcome studies. It is clear that if we are truly to have services redesigned to be the best then change must be based on hard evidence and not simply upon doctrinal belief.
So how then should change be implemented? Ministers have spoken at length about their desire to involve patients and staff within the process of service redesign. Translating that involvement into reality, to really convert the wishes of the service and the patients it serves into embedded change has been somewhat different. Involvement of staff in the process of change has been difficult - not because staff are unwilling to take part in the planning process, but because little effort has been expended in recruiting them. It is true to say that staff involvement has received more attention recently but it is yet unclear whether this has led to greater involvement of staff other than the “usual suspects” - those who are already heavily involved in service management. Even less clear, where staff involvement has actually been solicited, is what effect this has been allowed to have on the final outcome.
Working as an NHS consultant in the East of England, and as chairman of the BMA’s regional consultants’ committee, I have had some direct experience of the consultation process – firstly with the acute services review of the Eastern region’s health services and now Lord Darzi’s NHS-wide review. Our Strategic Health Authority has latterly adopted a more inclusive approach to medical involvement within the process of change. This is to be welcomed, not only because it is likely to facilitate the acceptance by NHS staff of any suggested change, but also because it increases the likelihood that proposed changes will be more effective.
Our vision for the NHS suggests that it should be truly designed around patients, provided by multidisciplinary teams working together and integrated across primary and secondary services. The local NHS should be given the freedom to decide how best to allocate resources and plan for the needs of their patients.
Change within the NHS has progressed at a rapid pace. This latest round of upheaval under the Darzi review is no different. Regions have been asked to assess, consult and report within just a few months - for change of this magnitude it would be wise to have a job done well, based on good evidence, rather than a job done quickly. As doctors, who lead in the development of new treatments and services, we recognise the value of evidence. Will this review of the NHS finally come up with the evidence that will convince doctors, and the public, that what they propose is right? Perhaps what the NHS most needs is evidence-based reform and a good deal less doctrine?