Clinical networks are effective, work in patients’ interests, and shouldn’t be disbandedBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f565 (Published 28 January 2013) Cite this as: BMJ 2013;346:f565
- Roger Boyle, director, National Centre for Cardiovascular Prevention and Outcomes, University College London and former national director for Heart Disease and Stroke
Clinical networks are an established part of National Health Service infrastructure. Over the past decade they have operated in specialist areas throughout the NHS in England and, in a different shape, in Scotland and Wales. They vary in form and function, from groups of interested clinicians who meet occasionally to more formal, managed clinical networks established for major conditions such as heart disease, cancer, and stroke.
These more formal networks bring coherence to clinical services for populations of 1.5-2 million, help centralise services, and try to standardise cost effective clinical pathways of care among institutions. They counterbalance the power of individual hospitals, which tend to try to retain business at the expense of optimal service configuration. The networks also provided a focus for local clinical leadership as national policies for major killing conditions were being implemented. The national service framework for coronary heart disease and the national stroke strategy were not conceived and delivered in Whitehall but drew from, and were delivered by, the grass roots of the NHS. The networks became part of a movement that developed and maintained service improvement. In time, this service improvement element was formalised under the umbrella of NHS Improvement, so that new learning as well as proved ideas and techniques could be shared and implemented throughout the country.
As successive governments pursued increasing competition in the NHS, which is almost without evidence of benefit, the networks became guardians of continuity and pathway development. They involve patients and carers in service redesign and act as guardians of the needs of patients. As clinical data emerged from national audits, allowing benchmarking between services, networks challenged individual providers about their contribution to these national yet locally delivered programmes.
Perhaps the greatest achievement of this system was the reduction in cardiovascular mortality by more than 50% in the past decade, with roughly half the improvement the result of better care throughout the system.1 As always in these situations, it is impossible to identify all the key factors that brought about such a huge decline, but strong evidence suggests that improvement in prevention in primary care and better treatment of heart attack have been major contributors. The work within networks on improving secondary prevention and similar activities has been key. The transformation of heart attack care over the past decade is singularly impressive. Although England may not have been the first nation to embrace primary angioplasty, it has certainly been among the quickest to roll out a national programme. Last year, 95% of patients ( some 20 000 cases) with ST elevation myocardial infarction received primary angioplasty, compared with only a handful a decade ago, and 92% of these were treated within 90 minutes of hospital arrival. Thirty day mortality has declined hugely over these years.2
These impressive results would not have come about without the clinical networks negotiating with providers as to how services were to be centralised, negotiating with ambulance trusts to ensure that they were appropriately resourced and their staff trained to triage patients, and persuading non-angioplasty sites that their cardiac care units remained viable for the wide range of acute cardiac conditions that still required local management if not primary angioplasty.
Survival rates after stroke have also improved greatly because the networks have led programmes centralising expertise, notably in London, Greater Manchester, and the Midlands. Imagine how the vision of a new stroke service for London would have been implemented, reducing the number of stroke centres from 31 to eight, without the negotiating skills of leaders and managers within local networks. In stroke we are seeing improvements in survival, length of stay, return to independent living, and reduced disability. What were the key factors? Direct admission to hyper-acute stroke centres by paramedics trained in FAST (face, arm, speech, time to call 999), immediate scanning and consideration for thrombolysis, and immediate admission to a specialised stroke unit. Networks also ensured that assessment and imaging for patients at high risk of transient ischaemic attack was available seven days a week. Another example was the introduction of simple software that enables general practices to identify patients who would benefit from anticoagulation to reduce their risk of stroke.
But it seems that clinical networks are casualties of the latest, disastrous reforms. The Health Service Journal reported that, of the 700 people employed in cancer, heart, and stroke networks, all but 70 would risk losing their job, a suggestion later denied by a spokesman for the National Commissioning Board. But messages are emerging from affected staff that they are either being put “at risk” or effectively being made redundant, and the response to a freedom of information request by the Labour Party showed catastrophic reductions in funding (about 15%) during the reign of the current government.3 4
It seems that generic clinical senates, backed by the National Commissioning Board, will take on the role, working with medical directors in four regional offices and local teams but concentrating on the five generic domains of the outcomes framework.5 This will hugely dilute the essential focus on major killing conditions, and the balance between national and local will be distorted. Just 12 clinical senates will cover large geographical areas, and their focus will apparently be on specialised services through clinical reference groups.6
Phases such as “the need for integration” are on many lips at the moment, usually in the context of the need to adjust how care might shift from hospital (expensive) to the community (cheaper), although almost no evidence supports this assertion. What we do know is that individual clinical pathways must be examined one by one to ensure that patients experience the best possible care at least cost. There are no short cuts. We simply need a combination of hard work and the right degree of focus at a local level so that small changes can, over time, make a difference. This hard grind has been the bread and butter of the clinical networks.
Cite this as: BMJ 2013;346:f565
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned; not externally peer reviewed.