This follows statements from the Royal College of Physicians – ‘we must radically review the organisation of hospital care’ – and the Academy of Medical Royal Colleges, which, in their call for a shift to seven-day consultant care, also argued that services will need to be reconfigured onto fewer sites. All the Colleges cite the need to adapt services to reflect advances in medicine and technology and the changing needs of patients, and therefore to drive up quality – arguments that have been made for decades.
So what is different about the RCS report? While arguing the clinical case for change, it also argues for meaningful engagement with the public on service change. Distinctively, the foreword to the report is written, not by the President of the College, but by the Lay Chair, Susan Woodward, who sets out the case for meaningful public and patient engagement. The tone of the RCS paper is a world away from the seminal paper Organisation of acute general hospital services produced by the Joint Consultants Committee (JCC) in 1999. In this the JCC pronounce ’It is important for the public to recognise that it is not possible for each locality to have its own small hospital to provide anything other than a restricted service.’
What flows from the RCS’s greater focus on the needs of patients seems to be an openness to try to find ‘win-win’ solutions or, at the very least, a means of mitigating the potential downsides for patients that may come from service change. For example, they propose the development of surgical clinical networks, supported by telemedicine and other technological support, with surgeons working across multiple sites. They also propose strengthened ambulance services with additional training for paramedics, allowing a model of care in rural areas in which patients would be triaged so that only those needing specialist care would have to travel long distances. The RCS also addresses some of patients’ key concerns by arguing that transport issues need to be central to any planning process; that consultation should be genuine and not tick box; and that any service change should be monitored and evaluated.
This should be music to the ears of the Independent Reconfiguration Panel (IPR), who are charged with reviewing contested proposals for NHS service change, as this closely aligns to their ‘critical list’ of key lessons learnt. This includes:
- the clinical case not being convincingly described or promoted
- clinical integration across sites and a broader vision of integration into the whole community has been weak
- proposals that emphasise what cannot be done and underplay the benefits of change
- health agencies caught on the back foot about the three issues most likely to excite local opinion – money, transport and emergency care.
The RCS’s approach is very welcome, and let’s hope that it translates into a genuinely different dialogue at a local level – a dialogue based on evidence. In my view, the problem is not just how we engage with the public but about the evidence on which the dialogue is based – the first issue on the IRP's critical list. For example there is little evidence of volume and outcome benefits for the majority of general medical care and such benefits that do exist have much lower volume thresholds than those in specialist surgery. Yet consultation documents often imply that the benefits are similar. It is also rare for the public to be shown evidence of current deficits in quality. The RCS suggests that greater use should be made of national clinical audit data. In our report on Improving health and health care in London, we found that the data showing variation in the quality of stroke services was very powerful in generating public support for change. If we are to have the ‘historic change’ sought by Professor Williams it needs to be change supported by robust evidence.