The NHS in Lewisham: a victory for natural justice?

Vox PopuliLewisham Healthcare NHS Trust is a mid-sized organisation (turnover in 2010/11 was about £220m) that includes acute hospital and local community services.  It produced a surplus of about £1m in that year, having overcome recurrent deficits to achieve sustained surpluses over a relatively short time http://tinyurl.com/p9yvq93. It epitomizes the successful integrated NHS organization: financially stable, well liked by its users, and expecting to achieve Foundation Trust status until external events overtook it.

Its misfortune was to be sited close to the vast, failing South London Trust, which was put into administration in July 2012, with losses predicted to exceed £60m annually. In early 2013, the Secretary of State for Health Jeremy Hunt agreed with the administrator (Matthew Kershaw, from McKinsey) that the Lewisham Trust should merge with part of the dissolved South London Trust, with the downgrading of its University Hospital and the closure of its A&E Department http://tinyurl.com/oqn57lu.

This decision was challenged legally, and a judgement has overturned it http://tinyurl.com/pn27366 , although the Government is considering an appeal.

The judgment is important, not only for the Trust, but for the messages it sends out about the NHS, its drivers, controls, and self determination. There are at least three main points:

1  Externally driven NHS Trusts may as well be directly managed units

Over the past few years, the Lewisham Trust has shown the value and impact of self determination.  It successfully overcame its financial problems, absorbed community services, and built up a reputation as a thriving, effective organization, a significant ‘player’ in its local health economy. If these achievements are discounted, and its future determined by Whitehall, then staff (clinical and otherwise), users, and local organisations such as the Council, will all see themselves as entirely disenfranchised; how that perception is incorporated into a political agenda of ‘localism’ poses an interesting challenge.

2  Expectations raised and dashed are worse than no expectations at all

The current NHS reforms in England are based on a few simple foundations. The first acknowledges clinicians’ impact on the processes and outcomes of health care by involving them in driving these; doing so produces a degree of ‘buy in’ and responsibility amongst clinicians, and develops a new and appropriate line of clinical accountability. The second is an extension of this: as general practitioners instigate most NHS spending through their prescribing and their referrals, they should be involved in the strategic spending decisions as well as the operational ones. This allows more rational and coherent planning, with the ‘ownership’ needed for responsible, accountable working.

The Clinical Commissioning Groups (CCGs) currently finding their feet are the organisational embodiment of these simple foundations, with responsibility for around two thirds of the entire NHS budget of £108 billion, and some influence over the rest. The key tasks they face in their first year are not only to learn to walk (by getting themselves established, and their members engaged), but also to run (by producing considerable savings, and starting to plan their future, more strategic activities).

These tasks would be hard enough, but if the application of their new found skills were to be immediately overturned by Governmental dictat, then all the efforts that have been applied in overcoming GPs’ natural cynicism about involvement in commissioning will have been wasted; the noise of the ensuing disenchantment is likely to drown out for many years any attempts to achieve the same aims.

3  ‘Vox populi’ is not democracy

If the lay press is to be believed http://tinyurl.com/qx2xvve , the recent judgement seems to have been driven entirely by local activists trying to save their hospital. Whilst local support is helpful, it would be bad for any part of the welfare state if national policy was only the result of local pressure.

The NHS was designed to be both egalitarian and utilitarian, and as such, ‘broad brush’ strategy needs to be driven in a systematic, rigorous fashion. The recent Health and Social Care Act http://tinyurl.com/pj3j4v3 suggests that decisions about service configuration should be made by CCGs working together, with appropriate input from NHS England, under the aegis of overarching Government policy. Whilst patients and the public are obviously important protagonists, it would be a dangerous precedent if major reconfigurations were seen to be driven by public demonstrations.

Finally, it is worth considering how the reconfiguration exercise might have been handled better. Once the South London Trust had been disbanded, it should have been the CCGs working with NHS England who made the strategic ‘macro’ decisions about the overall shape of service delivery; the operational details, the ‘micro’ decisions, should (in theory at least) been left to the new delivery organisations to define themselves, in response to an outline brief (‘what is required’) rather than any overprescriptive, micromanaged approach (‘this is how we want you to do it’). Broad brush strategic management needs the high level players to be involved, but preferably not the politicians; operational delivery is best left to those who know how to do it.

This piece is based on an article published in The Conversation on 1 August 2013, which can be read at http://tinyurl.com/p6wom8j

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