National services, local need


The notion that localism can be compatible with a National Health Service is, on the face of it, absurd. By definition, localism must mean a postcode service, or what is the point of it?

The real questions, therefore, are firstly whether it matters and secondly, whether it can lead to improved services for patients. I would strongly argue that with the right safeguards, localism is not only beneficial, but essential under this criteria. That being said, how can I, a GP, former Labour MP, and a passionate believer in the NHS, make this case with any credibility?

I currently Chair NHS Bexley Clinical Commissioning Group. We have a budget of around £250 million to purchase acute, community and mental health services for 230,000 people. This boils down to just over £1000 per head – in other words, not a lot. We have an elderly population, with amongst the highest rates of obesity, diabetes, and dementia in London. Because of this demographic, demand for services increases by around 5 per cent a year, but in real terms, resources have remained static over the last five years.

We constantly strive to improve patient services and outcomes by making the money go further each year. However, it is fairly obvious that expecting providers to deliver the same service to 5 per cent more patients each year for the same resource in real terms can only lead to disaster; many argue this is already upon us.

Let us not mince words. None of the political parties are promising anything like enough resource to fund the NHS if it continues as it is. The only solution is not to demand the same service for less, but to design a different one. Before alarm sets in, this does not need to be as disastrous as it appears. Many services are not fit for purpose, are not evidence based, and frankly, do not deliver good patient outcomes. We should not therefore be apologetic about de-commissioning them. There is nothing noble about throwing public money at a poor service. This wastes resources, and does no one any favours.

The trick is to redesign the services to maximize the use of scarce resources to give the best possible outcomes to patients. Can this be done on a national basis? Of course not. We can make national decisions about how much resource we devote to health, and what new drugs the NHS should provide, but not how a service is delivered. To make any sense of it, this must be done locally.

Let me give you an example from Bexley. We had completely separate services for orthopaedics, rheumatology, physiotherapy, and chronic pain management, despite the fact that these all cover the same group of patients  – those with musculoskeletal problems. Waiting times for physio were 24 weeks. Patients were referred between services, with even more delay. The costs were horrendous, the patient service very poor.

Some of our clinical lead GPs, working with our commissioning experts, redesigned the whole service into one pathway and awarded the contract to Kings College Hospital to manage the whole service. Waiting time is now four weeks for routine cases, and two weeks for urgent cases. Patient and staff satisfaction is extremely high, while the service is significantly cheaper, freeing up resource for other services.

But where do the patients feature in this new world of clinical leadership? In Bexley, we have set up a patient council, an umbrella organisation representing dozens of patient groups. Two of their members sit on our governing body and take part in all of our decisions. We also ensure that patients sit on every pathway redesign group and are genuinely involved in providing a user perspective.

We are also in the process of significantly improving two local hospitals which had failed financially and needed significant investment. We transferred ownership to an NHS Foundation Trust, which is able to invest £30 million over 3 years, to allow us to commission completely different services. We are constructing a new kidney treatment centre, and a world class cancer centre which will remove the need of patients requiring radiotherapy to travel. Each of the two hospitals now has an Urgent Care Centre which for a majority of patients obviates the need to go to A+E. They are run by GPs and expert nurses, waiting times are very short and patient satisfaction very high. We have also completely redesigned cardiology, and are in the process of significant improvement in children’s services.

There is much more we could achieve at local level. However, the obsession of this government on cutting running costs means we are starved of the number of commissioning experts we need to really transform patient care. By forcing us to save thousands on running costs, we waste the opportunity to save millions by radically changing how we deliver care.

Let us not be under any illusion. The NHS cannot survive without more resources, and it will not improve outcomes without transforming what it does. This transformation must be led by clinicians and patients working as partners, designing services based on local need.

This was first published by the Fabian Society