Diluting the evidence for reconfiguration
Posted on 30 November 2012 by Tony Bolton
It has been alleged by some that the health secretary is a fan of — gasp — homeopathy.
Putting judgements about the validity of homeopathy to one side, there are some interesting parallels between the practice and the preferred approach to reconfiguration of health services.
Homeopaths believe that a substance that causes the symptoms of a disease among healthy people can cure that disease in the sick. Despite a lack of evidence, this doctrine has existed since at least 1796. It isn’t dissimilar to the ideological drive to merge hospitals and downgrade services when trusts get into financial difficulties.
Bristol University’s Centre for Market and Public Organisation (PDF) studied the effect of more than 100 hospital mergers that happened after 1997. The centre observed a fall in overall work, and a deterioration of clinical outcomes and financial position. These results were broadly similar to studies of private hospital mergers in the USA.
The King’s Fund (PDF) has also failed to find any evidence for ‘concentric’ mergers solving the financial problems of insolvent trusts, or maintaining clinical outcomes.
Instead, the fund has proposed that the reforms that improve patient outcomes tend to be ‘radial’ — ones that follow established best-treatment pathways and are led by high-achieving foundation trusts, such as the reconfiguration of trauma, stroke and cardiac services in London.
On February 1, 2013, health secretary Jeremy Hunt will have to decide whether or not to accept the recommendations of the administrator for South London Healthcare NHS Trust. These include downgrading the UHL (University Hospital Lewisham) emergency department to an UCC (urgent care centre).
When the Joint Committee of Primary Care Trusts in South-East London began A Picture of Health (its review of the area’s hospital services), UHL was struggling financially and there were concerns about its ability to provide high-quality care.
Nearly seven years later, the trust has become solvent. In areas such as ICU, it is providing care that approaches the standard of a tertiary centre.
UHL has shown that trusts can deliver better care with the right management; short-term financial difficulties should not by themselves be used as a reason for service redesign.
I’ll never feel comfortable sitting on the same side of the fence as the Daily Mail, but its campaign against the closure of emergency departments does have merit.
Moves towards the centralisation of specialist services have driven improvements in some areas of medicine, but centralisation is not a panacea for reconfiguration ills. And, as an emergency medicine doctor, I don’t need to serve a population of half a million to maintain my competence in treating acute asthma, acute abdominal pain, hip fractures, renal colic and the many other common presentations that cannot be managed in an UCC.
And it’s certainly not what the public wants. Time and time again, patients choose local hospitals over the nearest tertiary centre that has better outcomes.
The NHS needs to change, but we must not allow reconfigurations to be dished out like so many homeopathic sugar pills. As doctors, we must demand evidence-based changes in consultation with clinicians and patients.
Tony Bolton is honorary secretary of the BMA London regional council
* If you are interested in the issues raised in this blog, you can attend 2020 Vision: London Hospital Services Reconfigured — a meeting at which London doctors will debate the reconfiguration plans for the capital.
accident and emergency