Do we need national outcomes strategies?

The editorial from the BMJ, the HSJ and Nursing Times criticising the damage being caused by the health reforms is the hot topic this week. But on Friday last week, the Lancet had an important editorial too.

It referred to a recent report by the National Audit Office, which concluded that neurological conditions remain neglected and ignored, and supported the call from the charity umbrella group the Neurological Alliance that the NHS needs a national outcomes strategy led by a clinical champion for neurological conditions.

The variability in the quality of neurological services is clear. There is evidence of late and missed diagnosis, rising emergency admissions, lack of access to specialists, poor information and support for patients, and poorly co-ordinated services. But would national strategies solve the problem?

Several of the National Service Frameworks (NSFs) of the early Labour years have been shown to have had significant impact on the quality of services. In our book looking at the effect of Labour's market reforms we argued that some of the more direct clinical strategies like the NSFs had considerably greater impact than some of the major policy levers like choice or competition.

Whatever the immediate outlook is for the Health and Social Care Bill, the signals from the government about the future for national strategies is mixed. On the one hand, there is strong rhetoric about devolution of power away from the centre. But on the other, there is a huge amount of scope left for the NHS Commissioning Board to get stuck in to the detail of strategy-setting for particular clinical areas. Indeed, if it is to deliver improvements against the Outcomes Framework, it might be keen to do exactly this. And several outcomes strategies have already been published since the election, such as cancer, mental health and COPD and asthma. The government is also committed to producing a new cardiovascular disease outcomes strategy.

Last week the Department of Health published its intended structure for the NHS Commissioning Board and its functions. At first glance, the associate medical directors for the outcome domains, the strategy group, the commissioning support and the improvement teams could all have an interest and a role in producing further outcomes strategies.

It remains to be seen how prescriptive the Commissioning Board might end up being. The proposed mandate that the Secretary of State will set for the board, if or when it comes out for consultation later this year, could be short or long. We could have ten new outcome strategies in development, or none. Central staff numbers will be smaller, so administrative resources will be scarce for their development. However, the precedents are there and sound arguments can be made for their value and for their rational place in the proposed new system.

The case for neurological conditions to get a new outcomes strategy is therefore compelling. But if the Neurological Alliance are successful in their campaign, perhaps the more important question is what will determine the strategy's success? The recent outcomes strategies are not NSFs. Of course, they don't have the same kind of new financial investment attached. But they can still have some of the other attributes we know particularly made the early NSFs effective: clinical leadership both nationally and locally, clear goals, alignment with other policy initiatives, and shared ownership between clinicians and managers, providers and commissioners, and staff and patients. While the important debates about the Bill rage on, real change and improvement for patients could quietly continue underpinned by strategies like these.

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