Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
User perception is everything
- Andrew G Craig (2 December 2006)
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Clinicians are fatigued by health policy and policy makers – show us the detail and then listen to our comments.
- Richard Venn, Lui G Forni (5 December 2006)
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A side effect of patient choice?
- Ike Anya (6 December 2006)
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Try reconfiguring services to improve standards and meet patient preferences.
- Steven Ford (7 December 2006)
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Changes need to be planned, not left to the market
- Stephen F Wilson, Rhonda Granger (20 December 2006)
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Andrew G Craig, Partner The Moore Adamson Craig Partnership LLP, London SW12 8LG
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Chris Ham cautions that changes in acute hospital services configurations should not come simply through the invisible hand of the market and that planning is needed. True enough, but the problem is that the public has to be a willing party to the plans. On present evidence their willingness to engage in this process is diminishing. People increasingly hate changes to "their" NHS, especially local hospitals. The reasons why reveal a divergence between personal experiences of using local NHS services (generally pretty good) and public perceptions about the NHS as a whole (often negative). When it was first reported in August that emergency care in some places would move to fewer regional centres, I analysed the BBC News Online feedback from this story. I found common threads of anger and mistrust in the 300+ responses. In rough order of priority these were: 1. The cost-saving argument is a sham; what is really needed is more hospital services not less 2. Bureaucrats are too powerful and have the wrong priorities because they focus on money and not care 3. Increasing travel times to get to A&E services will lead to more deaths and complications because care will be delayed 4. Relatives will find it a burden and more expensive to travel farther to visit people in hospital 5. Downgrading hospital services flies in the face of people having more choice about their healthcare 6. It is a betrayal of the NHS to close services because people have had no say in the changes Undoubedly there is a strong case to be made for providing more care, including urgent care, outside of hospitals. But once the 'save our A&E' placards are out, the time has passed for balanced discussion. It is a brave NHS manager who will contradict the paramedic whose intuitive wisdom was recommended most frequently in the whole BBC Online debate: "If accident and emergency services are further rationalised, then distances will increase and risks to patients will increase." Perhaps the problem is that we have unrealistic expectations of the NHS even at the present record high level of funding. What seems clear, however, is that a chasm is opening up between personal experience and public perception which could have electoral consequences. Politicians should beware: in consumer-focused healthcare, perception is everything. Andrew Craig Partner The Moore Adamson Craig Partnership LLP andrew@mooreadamsoncraig.co.uk Competing interests: Andrew Craig is part of a consultancy specialising in user and public involvement in health and other public services. |
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Richard Venn, Consultants in Intensive care Worthing Hospital BN11 2DH, Lui G Forni
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We are somewhat fatigued of reading reams of health policy & listening to health policy makers, advisors and commentators. We are continually told policy makers want to involve clinicians. If so then please show us the detail and listen to our comments [1,2]. Professor Ham quotes David Nicholson and references ‘Strengthening local services: the future of the acute hospital’ to emphasise the changes in how health care are to be provided to patients. He fails to explain that it is the clinicians who have piloted and worked to move patients from acute hospitals into other settings once we have been satisfied that this can be achieved safely. Those of us on the shop floor recognise that we have to make our hospitals ‘acuter’, and in a financially constrained Health Service this equates to moving the ‘less sick’ into less-acute hospital settings, as well as investment in the ‘acuter’ hospitals. Transferring the ‘less sick’ into non-acute hospital settings doesn’t necessarily save money. At least 15 schemes vigorously supported & in some cases piloted by our acute hospital, have been rejected or discontinued by the PCT on financial grounds. The University of Birmingham has reviewed the evidence for the cost-effectiveness of moving the ‘less sick’ into non-hospital settings & concludes that these changes will not automatically reduce costs [3]. Sadly this document also concludes that there is little evidence that this health policy will reduce reliance upon acute hospital care, despite the premise that there is a reduced need for acute hospital beds. Professor Ham states that ‘the NHS should make it clear why change is needed and articulate a persuasive and reasoned case to support proposals that are bound to be controversial’. We agree. What we don’t need are further eloquent health policy editorials and overviews to ‘clarify’. As clinicians, we have been driving these changes in a timely and safe fashion as a consequence of clinician-driven advances in medical care and the recognition of an ageing population whose health care expectations are rising. Clinicians are not the dinosaurs resistant to change which the DoH would like the public to believe. What we require is the detail to show that the rushed and financially driven current health policies are safe for our patients. Indeed the BMA’s stance on hospital reconfiguration is that ‘… changes to our hospital services must be based on delivering the highest possible standard of care for patients. Reconfiguration to suit political needs or decisions based solely on cost would be completely unacceptable’ [4]. Policies which are driven fundamentally by financial pressures are of course bound to be controversial, and Professor Ham as professor of health policy and management, would do well to highlight this to those who can influence DoH policy. 1. ‘Fit for whose future’. http://www.kwash.org.uk/ 2. NHS reorganisations: who's kicking whom, who's protesting?: Where are the medical voices raised in protest: fit for the future? Forni LG, Signy M, Venn RM. BMJ 2006 333: 752-753 3. Making the shift: a review of the written evidence. www.hsmc.bham.ac.uk/news/MakingtheShift6881.pdf 4. BMA News 2006 December 2nd, page 7 Competing interests: None declared |
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Ike Anya, Specialist Registrar in Public Health Medicine Department of Epidemiology and Public Health, University College London WC1E 6BT
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Professor Ham clearly illustrates the tension between the need for collaboration between hospitals to ensure appropriate location of specialist services and the opposing need to compete promoted by a pro- market policy agenda which undermines collaboration. However,the editorial does not explore the effect that the monomaniac promotion of patient choice to the exclusion of any other considerations may have had in fueling public opposition to reconfiguration. Patients and the general public have repeatedly been assured that all aspects of reform in the NHS have been driven solely by the desire to give them more choice and by implication better services. It is no surprise then that they find it difficult to understand why they cannot have an Accident and Emergency Department on their doorstep if they so choose. A recent national survey suggested that one in three people believed the NHS should provide "all drugs and treatments, no matter what the cost", while a further four out of ten believed that the NHS should provide the "most effective treatment, no matter what the cost". Against this backdrop, it is not surprising that the natural public resistance to change seems more resilient than ever on the subject of reconfiguration of services. The rising cost of healthcare, the advent of newer and more expensive drugs and the aging population of the United Kingdom all indicate a need for more robust public debate on resource allocation and use within the NHS. The failure of policy makers to lead and promote this debate is in part responsible for the current difficulties in selling reconfiguration plans to the public. Competing interests: None declared |
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Steven Ford, GP Haydon & Allen Valleys Medical Practice. NE47 6LA
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Editor The three rapid responses to date make excellent reading. Reconfiguration of services in Hexham has come with the replacement of the Nissen hut hospital with a PFI development. This, taken with the linking of services in Hexham with the hospital in Wansbeck, has resulted in some strange effects even if the objective standard of care has risen. A patient fracturing their NoF in the Hexham catchment area will be taken initially to Hexham for diagnosis and stabilisation - this might involve an ambulance journey of up to fifty miles. Then they will be transferred to Wansbeck, another fifty mile journey, for operation - they are now one hundred miles from home. On this second journey they drive past an even larger centre of excellence, Newcastle, which is a mere thirty miles from Hexham. An audit that I conducted recently on patients in my practice who had had a baby within the last year revealed that 100% of them wanted Hexham to have a fully featured 24/7 obstetric provision instead of the present excellent midwife led unit. Most of those who delivered in Newcastle commented adversely on the frantically over-busy environment there. The point I seek to make with these two illustrations is that local services and patient preference can be delivered, and geographically appropriate provision made with a little more thought than the market and politics usually permit. Whilst Hexham is destined to be a regional (?) centre of excellence for laparoscopic surgery there seems to me to be no compelling reason why it should not be a centre of excellence for other high demand services too - sharing Newcastle's, Carlisle's and Wansbeck's burden more sensibly and equitably. One giant provider per area has definite drawbacks, whereas two or three collaborating sub-maximal units would confer a host of benefits. Looking to the future - transport is going to become crippling expensive within the lifetimes of the new units. Infection control is easier in smaller physically remote units - if one is closed the other(s) can continue. Local people want local services - should we castigate them for being so hopelessly backward and having the temerity to have a preference and state it? Perhaps the putative variation in standards is a price they are willing to pay. At a recent meeting with Dr. Richard Taylor MP (a retired consultant physician, not a GP as stated in Ham's piece) I found that he has been able to forge a good and useful role in parliament and as a constituency MP. Why should aspersions be cast in his direction for displacing a party MP? Isn't that what the democratic process is supposed to achieve - a responsive local representative? Party politics is good part of the cause of the malaise that afflicts many aspects of our nation's life. We need far more independent MPs to prise the political toys out of the hands of the complacent, over weaning, self-indulgent, narcissistic oligarchies that currently supply the interminable round of pushme-pullyou politics. Yours sincerely Steven Ford Competing interests: None declared |
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Stephen F Wilson, associate professor St Vincent's Hospital, Victoria Street Darlinghurstnsw 2010, Rhonda Granger
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Professor Ham has raised some very important issues for planning the changes needed in future healthcare. The health experience in England has many similarities to the current Australian experience. The trend for increasing transfer of hospital services to community care is partly driven by the increasing demands on hospitals. It is also the availability of successful models of ambulatory and community care which have been successfully implemented in some of our area health services (1). The government policies suggested by Professor Ham to facilitate these changes are also starting to be developed in Australia. The New South Wales Government has placed avoidable admissions as its second priority after police services and before education in its recently released plan (2). Private health funding for episodes of community care are being established through legislative changes for private health insurance (3). The changes in Australia mean that funds will be able to pay benefits for a wider range of community services so that the best care can be provided in the most suitable location and yet still qualify for benefits that have previously been restricted to hospital care. As succinctly stated in this article, David Nicholson refers to the need to redirect resources “where most benefit can be achieved by patients”. It is critical then that we inform both Government and Health Insurers so they may support the delivery of care at the point where it is both cost effective and more importantly, where it promotes independence and empowerment of patients. Such a balance will assist in reducing the demands on an already overloaded health service. It is likely that policy will create a new market of health products through a financial incentive for community care and avoidance of hospital care. However, it must not be left entirely to market demand in an environment where the health system is showing signs of significant pressure. Quality of service delivery, appropriate response to all sectors of the community based on age, demographics, and income status must be considered. It will be important for all practitioners to maintain the high quality of care that our patients deserve in these new settings. 1.Wilson SF & Collins N. Ambulatory alternatives exist. Letter to the Editor. BMJ, 2002;325-389. 2.New South Wales Government. State Plan 2006, p78. 3.Australian Government. Private Health Insurance Bill 2006. Accessed on www.health.gov.au Competing interests: None declared |
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