Honesty, evidence and teamwork are essential
Posted on 9 November 2012 by Chris Clough
My role as chair of the NCAT (National Clinical Advisory Team) is to provide advice to reconfiguration teams but ultimately to give formal clinical assurance to plans before public consultation.
We’ve dealt with more than 150 schemes in the past four years, ranging from closing a small mental health ward to large-scale service redesign, and most of these reconfigurations haven’t been driven by the need to save money.
PCTs and now clinical commissioning groups want to improve care quality or respond to problems of sustainability. Throwing money at problems is often not an option.
Clinicians are often strongly supportive of reconfiguration led by national initiatives to drive up care quality but can turn against proposals if their hospital is not chosen.
All doctors need to understand the case for change and should put loyalty to the patient over loyalty to their host organisation. It is natural for people to support their local hospital. Often they tell us their main concern is access to services but most people recognise they might need to travel further for quality and that it is not possible to have an ‘all bells and whistles’ district general style hospital on every street.
We support the premise ‘wherever possible localise, where necessary centralise’ and have witnessed a genuine attempt by commissioners to bring services closer to patients’ homes. This has led to conflicts when the motive for change was largely financial but the evidence base was poor. Commissioners might want to see emergency activity directed to GP-led urgent care centres but the creation of such centres has not cut the rising footfall in emergency departments.
Reconfiguration will have to play its part in delivering savings in the next few years. I have no problem with that: as a tax payer I want to see resources prioritised appropriately to deliver high-value services.
Clinicians should not shy away from discussions about cost-effectiveness because the public needs to know what we think. Outcome-based commissioning will help sharpen our minds to what those choices are.
For instance, we now know from the Birth Centre Study that the outcomes for low-risk pregnancies are as good in midwife-led units as obstetric units, with fewer interventions and a lower cost. Presently most births are within obstetric units. We could conserve quality and save money by ensuring that many more women deliver in midwife-led services.
What are the four key ingredients for successful reconfiguration?
Early and persistent patient and public engagement. Our experience is that the public does understand the issues and can be strong advocates for change - don’t let the politicians get to them first.
Strong clinical leadership. A clinical lead who engages and listens to their colleagues but who sees the bigger picture of public health. It’s not just about the patient in front of you; we need to spread health resources wisely if we are to improve health outcomes overall.
Good project managers. We have witnessed much coming and going due to the current reorganisation and this can be disastrous. Project managers need to be supportive of their clinical leads and accountable directly to the execute team. Best practice is for commissioners and providers to come together, working to common objectives, so that agreed actions are implemented. We’ve got limited experience of commissioners going out to tender with service specifications, which may be the way of the future.
The case for change needs to be clear and evidence based. If it is about affordability, let’s be honest about that. After all, money spent badly on one service is a service cut elsewhere.
Chris Clough is chair of the National Clinical Advisory Team
clinical commissioning groups