News / News analyis: On the march

Few things will get up to 25,000 people onto the streets of
south London on a wintry Saturday in January, but the NHS is one of them. In this case they were protesting against a proposal to close a number of services at University Hospital Lewisham, including its A&E department.

The scale of the opposition will come as no surprise to those who have been or are involved in changing services. Last year’s decision on the reconfiguration of paediatric cardiac surgery attracted a judicial review and has yet to be finalised. It is currently being reviewed by the Department of Health. But Lewisham is perhaps a special case – a seemingly thriving hospital caught up in the shock waves emanating from South London Healthcare NHS Trust.

The South London trust’s financial issues led the Department to call in the trust special administrator (TSA) last year. His final report was published in January and health secretary Jeremy Hunt accepted most of the recommendations. However, bowing to intense public pressure, he decided to downgrade rather than close Lewisham A&E.

The TSA insisted a solution for South London could only be found by looking across the health economy as a whole. Lewisham faces financial challenges, though not at the level faced by the South London trust. The TSA forecast Lewisham would move into deficit in 2014/15 and 2015/16. And in aggregate, all south-east London trusts would have a financial shortfall of £82m by 2015/16, so a pan-trust plan was necessary.

Clinicians and finance managers alike predict there will be more and more rationalisation – and not just for financial reasons but also to boost quality and patient safety.

NHS Commissioning Board (NCB) chief executive Sir David Nicholson has said his new organisation, along with local commissioners, will push the NHS to reorganise, insisting the changes would lead to fewer units doing more.

Although the NCB will not fully take over its duties until 1 April, it has already announced a review of A&E and emergency care. To be led by medical director Sir Bruce Keogh, the review will develop a national framework that will aim to ensure high-quality, consistent standards of care throughout the country. ‘Treatments for many common conditions such as heart attacks and strokes have evolved considerably over the last decade and are now best treated in specialist centres,’ Sir Bruce said. ‘Yet we know people want their A&E nearby. This makes me think we need to review the increasingly complex and fragmented system of urgent and emergency care so that sick, anxious and often frightened people can get what they need, when they need it.’

Reconfigurations would have to take account of the review conclusions. While consultation points will be published in the spring, the Department is said to have already discussed designating A&E departments as 999 (emergency) or 111 (less urgent) centres.

The case for change

NHS Confederation chief executive Mike Farrar said the review was timely. ‘There is no getting away from the fact that the current structure of these services needs to change if we are to secure the best-quality patient experience, improve clinical outcomes and ultimately save lives,’ he said.

Mr Farrar was one of the signatories to a letter to the Guardian newspaper that backed reconfiguration, together with the leaders of the Academy of Medical Royal Colleges and royal colleges representing surgeons, GPs and paediatricians. They said the very future of the NHS depended on changes in service provision, including the closure or downgrading of some hospital services.

‘A big part of the problem is that too many services are in the wrong place. This often means that care is not as effective as it could be, and it is increasingly unaffordable,’ they wrote. ‘Sometimes it makes sense to travel further to be treated by high-quality specialists rather than be treated locally by staff who do not see enough patients with a particular problem to become adequately skilled.’

They recognised such changes were sure to be controversial and in the past the NHS had either put on hold or ducked them. But fudging the issue would make matters worse – with more NHS organisations becoming unsustainable and quality suffering.

‘Debates on this are happening all around the country. Local communities have to decide the best way forward, but no change is not an option. We must grasp this nettle – the NHS will not have a sustainable future unless we do,’ concluded the signatories to the letter in the Guardian.

Debates on reconfiguration are likely to become a common theme in healthcare – as may the kind of opposition recently witnessed in Lewisham. What is certain is that getting the best configuration that will please local people and commissioners is not going to be an easy task.