Will patients notice when NHS reforms go live in April 2013?

The biggest reforms in NHS history go live in April 2013, but will patients notice? The strap-line of Andrew Lansley’s baby was ‘no decision about me, without me’ but patients have had little say in the make up or operation of the NHS Commissioning Board, the Health and Social Care Information Centre, Health Education, the NHS Trust Development Authority, Healthwatch England, Local Healthwatch, Health and Wellbeing Boards and Clinical Commissioning Groups. Every year, the Health Service Journal produces a list of the people with ‘ the greatest influence on  health policy and the NHS’, and MD shows it to patients. This year, none could identify any of the top ten (hint: all white men, and four of the top six are called David).

At least Lansley became recognizable, but the current NHS is led by men you’ve never heard of who are miles away. For all the talk of devolving power to GPs, there are none in the top 20 and only one Clinical Commissioning Group chief in the top 100. Anna Bradley, the chair of Healthwatch England, ‘the consumer champion who will make the system listen to the patient voice’ is number 32. Despite fears that the NHS is being carved up for privatisation, the only private sector entries are Ali Parsa (58), who has just resigned as chief executive of Circle, and Richard Branson who has snuck in at 98 by virtue of his 75% stake in Assura and expansion of Virgin health.

A bigger fear for the government is that their hugely disruptive, expensive and widely opposed reforms will make very little positive difference to patients come the election. On top of the ambitious £20 billion savings plan over the next two years, the Nuffield Trust is now predicting a decade of austerity for the NHS, with a ‘funding gap’ of up to £54 billion by 2021/22. If every patient in the UK stopped smoking, ate and drank sensibly, took 30 minutes exercise every day, used condoms, stayed mentally well and only bothered the NHS for vaccinations, it might just survive.

Alas there are lots of chronic diseases without a cure, and these patients take up most of the NHS budget. Lansley’s test of whether the reforms are working is if a patient has a good idea to improve his or her care and takes it to a GP, the GP has the power to make it happen. MD suspects the results will be quite variable, but there are plenty of enthusiastic commissioning GPs across England who are already treating more patients closer to or in their homes, getting quicker access to consultants, getting city centre stores to stop selling cheap alcohol, liaising with charities, social services, pharmacies and opticians and cutting down on unnecessary referrals, A+E visits  and prescriptions.

There are also plenty of GPs in Scotland and Wales collaborating in this way, without the added pressures of a competitive health market, and only time will tell which model works best. And there are demoralised GPs in England who strongly opposed the reforms, think they’ve been stitched up in their new contract and resent the extra work and regulation for less money and pension. They may well have to make redundancies or end up selling out to Virgin.

Even the enthusiasts for clinical commissioning worry that, come April, GPs will be targeted by the press and blamed for hospital mergers and closures, increasing waiting times and lack of access to expensive drugs that are bound to happen in such austere times. Ultimately, the care patients get may depend on whether their GP is ‘energised’ by the reforms, or demoralised. Occasional NHS users will notice little change other than their GP looks even more stressed, but a few will have a personal budget to ‘shop around in the health market’. Those with multiple illnesses and complex needs will find life toughest, unless they’re lucky enough to find a bullet-proof workaholic GP who relishes the extra effort and responsibility of buying them the best care.

Will the BMA stand up for whistleblowers or shut them up?

IN JULY consultant paediatric surgeon Edwin Jesudason won a high court injunction with costs against Alder Hey Children’s Hospital (AHCH), which is seeking his “no fault” dismissal after certain surgical colleagues refused to work with him and surgeon Shiban Ahmed after they blew the whistle on malpractice and mistreatment of staff (Eye 1315). Next week, Jesudason hopes to make the injunction permanent. If successful, he may improve on the woeful statutory protections for whistleblowers by forcing trusts to follow their whistleblowing policies, or risk similar actions for breach of contract.

Jesudason, an award-winning surgeon who has never received a patient complaint or malpractice suit, has worked at AHCH since 1998 but since 2010 has been in the US on a Medical Research Council study. In 2009 he protested when Ahmed, who worked in AHCH and the University Hospital of North Staffordshire (UHNS), was suspended by UHNS after AHCH colleagues made the unsubstantiated claim that he was suicidal. The Eye has seen a 5.9.10 letter from surgeon Colin Baillie to AHCH which reads: “Shiban mentioned he had considered suicide. I have no doubt this was what was said because I asked him to repeat himself. I shared this with the clinical director Matthew Jones.” Ahmed knew nothing of this. The claim was made behind his back when a proper response to a genuinely suicidal colleague would have been to arrange an urgent mental health assessment. He was however suspended for 14 months pending an investigation which cleared him of being any risk to himself or his patients. He is still not back at work. This is a huge loss to AHCH as a Royal College of Surgeons (RCS) report found that “many members of the departments spontaneously described Jesudason and Ahmed as exceptionally skilled and talented surgeons”. Their crime has been to raise concerns about substandard care as the GMC obliges them to.

Jesudason led the petition to reinstate Ahmed and in 2009 made a confidential protected disclosure to AHCH which was circulated to his consultant colleagues, some of whom now refuse to work with him. Baillie’s 2010 letter is very revealing. ‘It is imperative that our legal position is solid should trust wish to terminate the employment of Jesudason… The allegations of patient harm go beyond the cases mentioned in this document, so we can expect more damaging revelations.  There are only two possible outcomes; major departmental restructuring (on the quiet) with Jesudason returning… or a very dirty fight, fully in the public eye, with the organisation’s chief weapon being to bring Jesudason (who remains a talented surgeon and researcher) before the GMC for sanction.’

The public interest disclosure act offers no real protection to whistleblowers against trusts with vast legal resources, and the CQC has shown no interest in policing trusts who break their own whistleblowing codes with impunity.  Represented by the BMA, Jesudason is arguing that AHCH is in breach of contract by failing to enforce the provisions in its whistleblowing policy. The trust now accepts Jesudason is a whistleblower, but argues that concerns regarding his working relationships with other surgeons have nothing to do with his protected disclosure in 2009, but ‘date back to 2004’, when he was a trainee. Odd then that colleagues now seeking his removal interviewed and appointed him to a consultant post in 2006.

Ahmed and Jesudason’s concerns have not been fully investigated, despite visits to AHCH from the CQC and RCS, who’s report has been redacted. In 2010, Dr Alan Phillips, head of psychological services, interviewed over 50 members of theatre staff and found “a significant number of highly de-motivated and demoralised members of the theatre team across all professional disciplines, and some very serious health and safety concerns”. The full report remains a trust secret and Phillips refused to sign a 2-page summary. He took retirement, with the customary gagging clause. The Eye has gone to the Information Tribunal to ask for the full report. Alder Hey still has skeletons in its cupboard and is fighting hard to keep them there.

M.D.

Closure of Lewisham ICU – where’s the evidence?

Matthew Kershaw, the Trust Special Administrator for the now dissolved South London Healthcare Trust (SLT), is making recommendations under the ‘Unsustainable Providers Regime’ that will result in the closure of the Lewisham Intensive Care Unit (ICU). Some closures are inevitable, but is this one based on evidence or simply cost cutting?

Lewisham ICU expanded in December 2006 into a combined ICU and High Dependency Unit (HDU) in a State of the Art facility in the new Riverside building, providing up to 21 patients with their own bay. It has space for an additional 3 ICU and 3 HDU beds and could provide a significant proportion of the services currently provided within SLT.

The Borough of Lewisham contains some of the most deprived wards in England. Deprivation is known to make severe, complex illness more likely. Despite this, Lewisham ICU is one of the better performing ICUs in the country (www.ICNARC.org). The standardised mortality ratio (SMR) is used to measure performance and quality of care in ICUs in England, and results consistently show that a patient admitted to Lewisham ICU is significantly more likely to get better than a patient admitted to a unit representative of the national standard of care

Lewisham’s ICU takes critically ill patients from all over London. In the last 12 months the ICU/HDU has looked after 772 patients at 94.9% capacity, with 34.8% on full life support and 12.6% requiring renal support. Kershaw’s current recommendations result in the net closure of 6 fully funded ICU and 8 fully funded HDU beds in South East London. No consultation with the critical care staff has taken place. Within Europe, the UK already has the smallest proportion of acute hospital beds allocated to critical care with 3.5 beds per 100,000 people. Germany has 24.6 per 100,000 and the US has 20 per 100,000.

Lewisham is the only DGH ICU in London that has been recognised by the Faculty of Intensive Care Medicine (FICM) as of sufficient quality to train the intensive care doctors of the future. It provides a consultant intensivist led outreach service that provides daily review, advice and expertise to all the other specialties to help recognise and initiate the prompt treatment of patients who may be deteriorating in the hope that we can stop them needing intensive care at all.

Lewisham ICU also conducts regular patient, relatives and staff wellbeing surveys. The responses are universally positive responses and these results have been presented at international meetings. The physiotherapists, pharmacists, nutritionists, speech therapists, radiographers, clerks, cleaners, 66 nurses, 9 doctors in training and 7 consultant intensivists have worked hard to deliver a truly excellent service serving such a deprived area, and understandably don’t want their service to be shut down.

The biggest challenge for those overseeing the current wave of NHS reorganisations is to provide robust evidence to those whose services are going to be disrupted, downsized or closed that the new service will be better. This has undoubtedly happened with the reorganisation of stroke care in London, partly because it was properly planned, consulted on and coordinated. SLT became a financial disaster in part due to two ridiculously unaffordable PFI developments, and the fear is that high quality services may now close. A final report will land on Jeremy Hunt’s desk in January.