Is it shortsighted and parochial to campaign to save local hospital services? This was the theme of a radio interview I listened to last week with Joan Ruddock and Ara Darzi. Darzi was arguing that politicians can be too defensive and parochial in their health campaigns and that his review of stroke services in London, which has brought better and safer services, would have been prevented by this sort of campaigning. Darzi contributed an enormous amount to Labour’s progress on healthcare, but he was wrong to allow himself to be used in opposition to the current campaign to save services at Lewisham hospital or, in fact, many others around the country including the excellent Save the Alex campaign in my former Redditch constituency.
In my view, there is a clear distinction between reform to improve the quality of services backed up with robust clinical evidence which is fully communicated to those most affected whether staff or patients and cuts to the quality of basic hospital services due to financial or recruitment issues which should and could be tackled. The Lewisham case is clearly about cutting the services to one part of south London due to financial problems in another part. You don’t need to be a highly qualified clinician to know that this is wrong.
The Redditch story is more complex and has been going on longer, but demonstrates why local politicians have a key role to play. There have been three attempts in the last 15 years to downgrade the A&E and maternity units at the Alexandra Hospital, Redditch. On each occasion, the argument has been that this is crucial for sustaining a high-quality, properly staffed service and that it will be better for people if services are concentrated in Worcester (over half an hour away in a car). I led the successful campaigns against these proposals on the previous two occasions as the local MP. My arguments were threefold.
First, A&E and maternity are core hospital services. For most healthy working-age people, their only contact with a hospital is likely to be in one of these two services. It isn’t unreasonable to expect that they’ll be delivered in mainstream NHS district hospitals. I accept the argument that there are some services – stroke, specialised surgery, rare diseases – where evidence does suggest that concentrating specialist skills and resources in fewer centres can save lives. I supported changes in these sorts of cases as the local MP even when it meant removing some services from Redditch or other nearby hospitals. However, those responsible for managing the NHS should not underestimate the significance of accessibility to core services for maintaining support for a publicly funded NHS.
Second, clinicians should certainly be asked to provide expert analysis and recommendations, but they don’t always agree and they’re not always impartial. I never saw any clear evidence of clinically better outcomes for the proposals to downgrade services in Redditch. Clinicians in one part of the county often disagreed with clinicians in another part or with GPs. There was a strong case made that there was a shortage of clinicians willing to work in Redditch, but I pointed out that this was likely to be because there was a constant threat hanging over the departments. Furthermore, when consultants became willing to travel between sites or share their rotas, this problem could be solved. This is an HR problem, not a clinical one, and it needs strong managers to solve it, not to cave in and start organising services for the benefit of clinicians rather than patients.
Third, politicians can often point out that the decision-making bodies for reconfigurations of services are political and bureaucratic constructs. Redditch is as accessible for the Birmingham trusts as it is for Worcester. However, there is very little imaginative thinking about how boundaries can be crossed either by patients or staff in order to provide better and more convenient services. I pushed for this in the last Redditch campaign. Last week, those involved in the current Worcestershire ‘service review’ admitted that they’ve begun to make the links across boundaries again. It’s taken a year!
Let’s resist the calls to keep politics out of NHS reorganisations. The NHS is not apolitical – it was formed from political conviction, it is funded by political decisions and its core principle of healthcare free and accessible at the point of need is the basis of its considerable public support. Local politicians and local people should be at the heart of decision-making – however difficult it is.
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Jacqui Smith is former home secretary, writes the Monday Politics column for Progress, and tweets @smithjj62
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I completely agree with much of what you say. It is certainly true that political issues dominate some proposed reorganisations, such as the potential closure of Lewisham A&E. Nobody tried to pretend that this was prompted by concerns about quality and safety of patient care; the plan was entirely due to the financial failure of neighbouring hospitals. As an ex-consultant married to a surgeon/ medical director I am concerned that financial and political motivation will increasingly dominate hospital reorganisations.
The issue of safety is different. I don’t know the circumstances of the maternity unit at Redditch, but the organisation of maternity services across the country is currently under review, and it may be that there are fewer, larger obstetric units dealing with higher risk mothers, and more hospital-attached midwife run units for lower risk mothers. The current arrangements for maternity care are not sustainable for several reasons, including the increased number of higher risk pregnancies, the shortage of midwives, and an ongoing shortage of obstetricians.
Jacqui is correct in saying that clinicians in different parts of the country do not always agree with one another – those working in the same trust don’t always agree! More seriously the rift between primary (GP) and secondary (consultant) care is widening. I believe that this is entirely attributable to the purchaser-provider split, and the advent of CCGs is likely to aggravate this. Instead of GPs and consultants working together for the benefit of patients, market (financial) forces now continually undermine this. I have experienced this in my own practice, when complex patients sent to my clinic for advice about treatment do not receive what I have recommended because the GP decides that his/her budget cannot accommodate it. (I am not talking about drugs costing hundreds of pounds.) This sort of thing undermines the patient’s faith in those looking after him or her.
So yes, healthcare is political – highly political. I believe in the NHS, it is why I trained to be a doctor, and its breakdown is why I am no longer practising. Conservative ideology does not believe in a universal, state-provided NHS, free for all at the point of delivery. I do. That’s political.
But Jaqui, the robust evidence which you advise should be present before reform is undertaken was absent during New Labour’s reforms. Indeed, Professor Allyson Pollock was replaced as special adviser to the Commons Health Committee because, in a series of articles in the British Medical Journal, she destroyed the economic case for PFI. New Labour rejected robust evidence in favour of an un-evidenced ideological ambition.
Unfortunately the political conviction behind much of New Labour’s marketisation reforms has more in common with the Tories current approach than it does with the intentions of Labour politicians who founded the NHS.