What do Department of Health reform pledges mean for the NHS?

The King's Fund Chief Economist John Appleby examines the latest pledges from the Department to ensure that patients' best interests will be at the heart of changes to local health services and argues that potential variations in services, following the SHA regional plans will need to be handled carefully by ministers and PCTs.

Publication:  The King's Fund bi-monthly update
Reference:  The King's Fund bi-monthly update, May 2008

Since the day the NHS opened for business there have been arguments over where services should be located and who should decide. Behind the rhetoric there is, of course, the difficult task of balancing trade-offs between cost, quality of care and patient access.

The leaflet delivered to homes announcing the opening of the NHS trumpeted that, 'Special premises known as Health Centres may... be opened in your district. Doctors may be accommodated there instead of in their own surgeries, but you will still have your own doctor to give you personal and confidential treatment.' The 1956 Guillebaud Report subsequently noted that such health centres may increase costs and reduce ease of access to GPs. Then came the 1962 Hospital Plan, followed by numerous initiatives and reorganisations.

And now we have the latest review of the NHS, led by Lord Darzi and due to report in early July. Billed as a 'once in a generation review' it will set out a vision of how services could be reorganised to improve quality of care, and to respond to changes in public expectations and advances in medical technology.

The intentions of this and its preceding London review are indisputably honourable – everyone involved wants the best outcome for patients. The problem – and it is a common one – is that the public can be sceptical, especially when it comes to changes to the fundamentals of the NHS.

So, in an attempt to allay public anxiety, the Department of Health last week published a set of pledges stressing that local people's views will be taken into account and that patients' best interests will be at the heart of any change.

What do these pledges mean and will the NHS be able to keep them?

Any change will always be to the benefit of patients. Although this is obvious, it’s certainly worth emphasising. But what happens when change benefits one group of patients but disadvantages another? Or, in the case of Lord Darzi’s polyclinic/health centre ideas, how do we tackle the trade-offs between easier access to devolved outpatient services and slightly more difficult access to GPs?

The King's Fund will publish its analysis of the opportunities and risks of developing polyclinics in early June. The report will concentrate on the 'big building' model and examine the impact polyclinics would have on patient care. The government's ambition for developing more patient-focused and integrated models of care is welcome, but poor implementation of this model could compromise patient care.

Change will be clinically driven. The NHS should not waste money on clinically ineffective care. But there is a limit to what the evidence can tell us. We often don't know whether a service is safer delivered in a hospital or community setting. Some clinicians have conflicts of interest, either because of professional rivalries or because of financial interests.

Change will be locally led. Reconfiguring services to reflect local needs means that services will be different in different parts of the country. It makes sense that different services might be needed in Newham and in Newcastle, but people will want to be assured they are not being short-changed. Potential variations in services following the SHA regional plans will need to be handled carefully by national politicians and PCTs.

People will be involved. But consultation does not mean local people will get everything they want. PCTs draw up their commissioning plans based on the needs of the community, but providers will ultimately decide (in the case of foundation trusts in conjunction with Monitor) whether a particular service is financially and clinically viable. There is a need, therefore, for a level of honesty about who has control and how trade-offs are going to be resolved.

Patients and the public will see the difference first. But proving that any changes are worthwhile can be difficult. When service changes involve closure of one unit to facilitate the opening of another, inevitably  the public will focus on the former not the latter. 'Double running' may overcome this, but can be very expensive. And the long-term capital commitments of private finance initiative projects mean there is a danger that double running costs will become more permanent.

The appointment of a clinician as health minister was in part an attempt to say 'here is someone we know you can trust'. The fact that it has been felt necessary to publish these five promises suggests how hard it can be to overcome public scepticism.