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BMJ No 7128 Volume 316
Education and debate Saturday 31 January 1998
The New NHS: commentaries on the white paper
Challenging times for specialist services
Christopher Bunch
The white paper focuses to a large extent on dismantling the internal market and the development of primary care. The provision of specialist services - which investigate and treat the bulk of serious ill health - get scant mention, despite their accounting for about £1.4 billion of NHS expenditure annually.(1)
| In an almost throw away line, the white paper insists that "everyone with suspected cancer will be able to see a specialist within two weeks of their GP deciding they need to be seen urgently and requesting an appointment." It is not difficult to understand why cancer has been singled out for this treatment. It is a common and greatly feared disease. Much work has been done around the country following the Calman-Hine report(2) to set standards for cancer care, define protocols and guidelines, develop multidisciplinary teams, and identify appropriate specialists. It is not unreasonable to suggest that a patient whom a general practitioner thinks is likely to have cancer should see an appropriate professional (usually, but not necessarily, a specialist) without delay. |  |
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| The white paper is silent on future development of specialist services Photo: ULRIKE PREUSS |
A two week target may seem as arbitrary as a 30 minute wait in outpatients but if achieved will reduce unnecessary anxiety and increase patients' confidence in the service.
As with much of the white paper, the devil will be in the detail. The wording here is specific, but it is left to the general practitioner to decide if the referral is urgent. A danger therefore exists that anxiety in either the patient or the doctor, rather than the probability of cancer, will be the major determinant of urgency. If this is the case specialist services will probably become overloaded with patients who do not have cancer and will find it difficult to maintain the standard. The appropriateness of referral should therefore be assured by developing tight and clear referral guidelines with the specialist teams. Patient anxiety should be allayed by well informed general practitioners and possibly through better public education. NHS Direct - the proposed new telephone helpline - may be useful here.
The only other significant reference to specialist services relates to the commissioning of services that are provided to more than one health authority. These include the old "regional specialties," so called because the old regional health authorities used to be responsible for specifying and funding them, and range from haemophilia (very low numbers, extremely high cost) to coronary intervention (very high numbers, moderately high cost). The smaller specialties felt particularly disadvantaged by the 1989 reforms,(3) which made health authorities responsible for purchasing them - because many individual health authorities did not give them high priority or fully understand their requirements.
The Audit Commission recently highlighted these concerns(1) but did not recommend a fundamental change in health authorities' responsibility for commissioning specialist services. The white paper, however, gives the NHS Executive's regional offices a clear responsibility for ensuring that effective arrangements for commissioning these services are established in each region. This is welcome and should help to overcome some of the difficulties encountered by specialist providers.
One important issue not covered directly by the white paper is the future development of specialist services, and in particular where, who by, and how much we can afford. Already it is becoming more difficult for smaller district general hospitals to provide some of the commoner specialist services - for example, urology, ear, nose, and throat surgery, and oral surgery. Changes in working patterns, in higher specialist training, and in the availability of staff make it likely that specialist services will in future be provided from fewer hospitals. Specialist care tends also to be associated with high cost interventions: bone marrow transplants, beta interferon, and taxol chemotherapy, for example. The new government promises a year on year increase in NHS spending (as did the last), but rejects the affordability argument and proposes better resource management, use of technology, and a reduction in bureaucracy as ways of countering present financial pressures. Given the focus on developing primary care that is clearly the cornerstone of this nation's healthcare philosophy, one can predict challenging times ahead for the specialties.
Oxford Radcliffe Hospital NHS
Trust,
The John Radcliffe,
Oxford OX3 9DU
Christopher Bunch,
medical director
References
1 Audit Commission. Higher purchase: commissioning
specialised services in the NHS. Abingdon: Audit Commission
Publications, 1997.
2 Calman KC. Policy framework for commissioning cancer
services. London: Expert Advisory Group on Cancer, Department
of Health, 1994.
3 Secretary of State for Health. Working for
patients. London: Department of Health,
1989.
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