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January 26, 2012 9:42 pm
The chief executive of the NHS has warned that his “greatest worry” for the government’s flagship reform programme is that hospitals could take “short cuts” in the drive to make savings, describing it as “a very dangerous place for the NHS to go”.
Sir David Nicholson told the Financial Times that the NHS was undergoing “a complicated and risky set of changes”, and called on David Cameron and other senior ministers to display “political leadership” by backing different ways of delivering services.
Londoners, in particular, could see key services such as cancer and emergency care concentrated in a much smaller number of centres, Sir David said.
A health service lifer who joined straight from university in 1977, Sir David describes himself as “the fully socialised [NHS] article with all the strengths and weaknesses that that has”. He will next year become the first chief executive of the NHS Commissioning Board, commanding a budget running to many tens of billions of pounds and overseeing GP-led “clinical commissioning groups” that from next year will buy care for patients.
Rumours are rife that Andrew Lansley, eager to inject a dose of private sector discipline into the health service, wanted to replace him with Mark Britnell, head of KPMG’s global health practice and a former member of the NHS management board.
But Sir David was the only person the Treasury trusted not to lose control of the money – and the Treasury won.
Thus far, George Osborne’s faith seems justified. Despite an essentially flat settlement in the spending round, he says the NHS will this year generate a surplus of more than £1bn and is confident of delivering another surplus over the coming year.
Key to this aim, though, is ensuring that more people are treated outside expensive acute hospitals. “At the moment, on any one day, a quarter of all hospital beds are full of people who shouldn’t really be there. If there were better services . . . in the community, you wouldn’t need them.”
A second element involves centralising services – a change “not driven by money actually”, he said, but by the knowledge that quality improves when a patient is treated by a clinician who sees larger volumes of people with the same condition.
As a corollary, some parts of the country will lose services – a nettle many health experts believe the coalition government has so far been reluctant to grasp because of the potential electoral fallout.
Sir David wants more evangelising from his political masters about the need to reshape the way healthcare is delivered. “We’re going to absolutely require top-level political leadership . . . from the very top, the prime minister, Andrew Lansley . . . ” he said.
This is not, he says, a question of closing hospitals : “It’s a shifting of service, it’s a concentration of service.”
A template exists in the shape of a spectacularly successful reorganisation of services for stroke victims in London. The number of hospitals allowed to treat them was whittled down from 31 to eight. The result has been a big improvement in patient outcomes.
Sir David suggested that over the next two to three years, “the stroke model” could be applied to “cancer, major trauma, coronary heart disease – there’s a whole series of services that we need to see concentrated in places.”
Asked what he sees as the biggest risk of the reforms, Sir David made clear that it is hospitals focusing on “the cutting bit” because they are “trying to keep doing everything”.
He cited events at Mid Staffordshire general hospital, where hundreds of patients are believed to have died unnecessarily as it sought to stabilise its finances before an attempt to become a free-standing foundation trust. “The worst option for me is that organisations – because they don’t do the service change – are left with the situation of simply cutting their costs and that is a very dangerous place for the NHS to go.”
MPs on the health committee suggested in a report this week that the distraction caused by preparing for the reforms was complicating its target of making £20bn in efficiency savings by 2015 – what Stephen Dorrell, committee chairman and former Tory health secretary, has pointedly dubbed “the Nicholson challenge”.
Rejecting that analysis, Sir David argued that the two objectives go hand in hand, because the move to put more power in the hands of family doctors can help to address one of the weaknesses of the system in the past: “the lack of clinical engagement on the commissioning side”.
He added: “But I do not underestimate how difficult it is and there is, as far as I know, no healthcare system in the world that’s done this.”
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