Will reconfiguration improve quality and save money?

The coalition government wants England to achieve the best health outcomes in Europe and deliver year-on-year productivity savings of at least 5 per cent – a twin challenge that many believe will drive the closure of hospitals and the reconfiguration of services.

Yet one of the first actions taken by the Secretary of State was to halt the proposed reconfiguration of hospital services in London, a reconfiguration that NHS London claimed would save £5.1bn and drive up quality. He was quoted at the time as saying:

'A top-down, one-size fits all approach will be replaced with the devolution of responsibility to clinicians and the public, with an improved focus on quality.

'It will be centred on a sound evidence base, support from GP commissioners and strengthened arrangements for public and patient engagement, including local authorities.'

What is the evidence base for reconfiguration? Will it drive up quality and save money? And if it does, will current policy act as an enabler or an obstacle to beneficial change? A recent seminar at The King's Fund explored these questions, drawing on a review of the current evidence base including an in-depth analysis of the reconfiguration of services in south-east London: A Picture of Health.

The professional bodies have long argued that bigger is better and college guidance has frequently been used to drive the centralisation of services. Yet when you look at the evidence you find it is less clear cut. Clinical outcomes depend not only on how many patients clinicians see (the practice makes perfect argument), but on how they work, overall staffing levels, the competence of individual clinicians, and the resources that they can draw on. Being good is not the prerogative of large hospitals and being bad is not the prerogative of small hospitals. However, the current service configuration is in large part an accident of history, and in an environment where money and the skilled workforce are constrained, there will be some compelling arguments for change on the basis of both quality and cost. The NHS cannot afford to do everything everywhere, and services need to move towards best clinical practice.

As an example, the recent changes in stroke services in London are starting to show some quite startling improvements in quality. Although patients are still being treated by the same stroke physicians, the new model of care means that those physicians can call on better resources and patients are more likely to be seen by a consultant than previously.

So will the new policy environment support beneficial service change? In many respects the signs are not good. Where will the strategic leadership for change come from? Where are the incentives for organisations to work together to deliver the service models that meet patient, and not organisational, needs? If the coalition government is to achieve its ambition of creating a world-beating health service it needs to apply its focus on outcomes to help drive improvements and encourage – not obstruct – service change.

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Comments

#459 Attilio Lotto
Consultant Congenital Heart Surgeon
Glenfield Hospital

Hello and good morning,

As you might be aware the 11 paediatric cardiac services around the country providing surgical and interventional treatment to patients with congenital heart disease are undergoing a massive reconfiguration process called Safe and Sustainable. The process has reached a stage where 4 options of reconfiguration (2 options with 6 centres and 2 option with 7 centres) have been proposed where some centre will close and other will take over the work. In 3 weeks the 4 moths long public consultation will come to an end and results will be announced next autumn. There has always been concern about the evidence that the bigger the volume of patients treated the better the results.

More recently questions about the risks involved in closing centres and allowing other becoming too large have been drawn, but poorly addressed. This is probably, in my opinion, due to a lack in a mandatory, robust, mortality and morbidity risk analysis performed by the Safe and Sustainable commission on the proposed options and their implementation. Moreover as part of the same review, some paediatric heart specialised services, namely ECMO, could be moved from the world leading centre to a new centre with little experience. Again no risk analysis has been performed on this very high risk task.
My question is, can a NHS organisation like the safe and sustainable review group, be held accountable by taking such risky decisions without deeply analysing the risks involved in it?
I thank you for you time, please feel free to contact me if more information is needed on the topic.

Mr. Attilio Lotto

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