Campaigner's Diary

Articles from John Lister's regular column in the Morning Star, plus other articles for publication.

Select an article from the list below

Doing the Darzi shuffle
May column, Morning Star

May 2008

Gordon Brown's new surgeon-minister Lord Darzi has just set the cat among the pigeons by announcing a new set of guidelines that could scupper controversial government plans to centralise hospital and primary services, and close down smaller hospital units.

For those of us who have been campaigning to stop the threatened cull of district general hospitals and accident and emergency units, which has been an explicit part of NHS management plans since 2005 and the grim days of Patricia Hewitt, Darzi's "tough rules for changes in the NHS" are a welcome retreat in the face of public opinion.

But for NHS Chief Executive David Nicholson, who took over in the autumn of 2006 pledging to "review" and "reconfigure" services in 60 hospital trusts in England before the next election, it will be another setback, and the plans of several Strategic Health Authorities have been thrown into disarray.

Although a handful of government loyalists, backed up by a few Blairite think-tanks and tame academics have backed the call for closures and reorganisation, there has never been any evidence of wider public support, with medical opinion divided. Campaigns to defend local hospitals have continued - including the recent victory by campaigners fighting cutbacks at Banbury's Horton Hospital, who secured the first intervention by the so-called Independent Reconfiguration Panel to overturn a major planned cutback.

Now Lord Darzi's five pledges, claiming to "ensure that change is transparent and driven by the best evidence", promise that:
  • "Change will always be to the benefit of patients". This potentially re-opens debate in many areas over issues of access and the potential impact on patients when local services face closure.

  • "Change will be clinically driven" - this will raise fresh question over changes which have quite clearly been motivated by cash pressures, including (as in South East London) the knock-on costs of Private Finance Initiative schemes in adjoining areas.

  • "All change will be locally led". While there is a debate to be had over how "local" is "local" - the ten Strategic Health Authorities in England, spanning populations of millions and large geographical areas, are far from local and in no way accountable to their catchment population - this raises the possibility of specific local needs being forced back on to the agenda where plans have previously attempted to impose inappropriate policies. Where - as in South East London - health bosses have manifestly failed to deliver any evidence of local public support for a closure plan, this pledge should logically rule out the unpopular changes.

  • "You will be involved". Here too there is room for debate on what "involvement" means, but Darzi specifically states that "NHS organisations will work openly and collaboratively" - which seems to undermine those Primary Care Trusts and Strategic Health Authorities which have been seeking to force through changes without proper consultation and disclosure of relevant information.

  • "You will see the difference first": this is potentially the most far-reaching pledge, since it commits NHS bosses to establishing new and improved services BEFORE existing services are withdrawn and buildings closed. This promise alone - with its clear implication of double running costs, and the pressure to resolve many of the issues left deliberately vague by local health bosses - would be enough to bring most of the planned rationalisation of services across the country to a grinding halt.
Coming as they did hard on the heels of New Labour's drubbing in the local elections, hitting a 40-year low in public support, it seems pretty clear that Darzi at least is flagging up the need to put more unpopular closures on hold until after the next General Election.

Perhaps this indicates that he has actually picked up some real sense of the unpopularity of these policies in his £1m "listening" exercise, in which he has claimed to have "engaged" with over 60,000 people in set-piece review events around England.

Or maybe it suggests that this unelected minister has slightly more political nouse than some of his head-banging Blairite colleagues and predecessors, who have been oblivious to the logic that having dug themselves so deep into trouble the least they should do now would be stop digging.

Darzi's retreat is not limited to hospital closures: he has also tried to distance himself from the notion of large-scale "polyclinics" as a new model for primary care, despite having spelled out the idea in great detail in his report last summer for NHS London. In an interview with the Times Darzi claimed his policy - advocating 150 polyclinics, each covering catchment population of around 50,000, should be set up in London - had been "misunderstood":

"The idea that I am going to herd all GPs into one large building is ludicrous … there are very good examples of federated models where you have five or six practices that have access to a diagnostic service". (Times April 1 2008)

But a reading of the 50-page "technical paper" that accompanied Darzi's "A Framework for Action" reveals that all of the outline costings and assumptions centre on the use of a single centralised building per polyclinic. More significantly, Darzi's national review of the NHS has continued to stress the notion of large-scale 'one-stop shop' polyclinics or "health centres", and to raise the possibility that some or all of these would be built and run by the private sector, not least the ubiquitous Richard Branson's Virgin group.

Whether or not Darzi is still wedded to his polyclinic idea, it is increasingly obvious that hardly anyone else is. A recent letter in the Health Service Journal from Patient Concern points out the unavoidable fact that there is no public lobby at all behind the proposal "Patient Concern has yet to hear from any patient who wants a polyclinic".

This gaping lack of support has also been palpable in the very few public debates and detailed discussions that have taken place on the Darzi plans for London. At the end of NHS London's ludicrous £15m charade of a "consultation" just 932 people registered support for the idea that "almost all GP practices in London should be part of a polyclinic, either networked or same-site", while slightly more (966 people) said that they "tend to agree" with the nebulous idea.

This endorsement from a thumping 0.033893% of the Greater London electorate, dressed up by NHS London as 51% of the 3760 responses which answered the question, was trumpeted in the Guardian with the headline "Public in favour of polyclinic scheme for London, says NHS". By contrast the Health Service Journal more prudently headlined "Polyclinics 'pie in the sky,' finds capital consultation".

Meanwhile the body of opinion questioning the evidence behind the government's pell-mell dash towards market-style reforms of the NHS, based on the "purchaser-provider split" and the concept of "commissioning" services, has been boosted by the one-time Blair government advisor and Birmingham University academic Chris Ham.

In a "high level overview" report commissioned by West Midlands health bosses*, Ham concludes that:

"Experience and available evidence from Europe, New Zealand and the US indicates that in no system is commissioning done consistently well. …

"Put simply, the challenge in making systems based on a separation of purchaser and provider roles work effectively, reflected in the experience and evidence summarized here, may mean that integration offers a more promising way forward."

None of these retreats and divisions at top level guarantees that local services will be safe from the logic of the market reforms already unleashed. But they do open new avenues for campaigners and trade unions to challenge unpopular and damaging closures that seemed set to be forced through in the next few months.

Let's not waste the opportunity: who knows when they all may change their minds yet again and embark on another barmy package of reforms that nobody wants?

John Lister's book The NHS After 60: for patients or profits? was published at the end of April by Middlesex University Press, £25.

* Ham C (2008) Health Care Commissioning in the International Context: Lessons from Experience and Evidence, University of Birmingham Health Services Management Centre, www.hsmc.bham.ac.uk

BCM London Health Emergency • London WC1N 3XX • Copyright © 2008 London Health Emergency