Colloquia: ministering to clinical priorities or political ones?

In this week’s Colloquia, Health Policy Insight editor Andy Cowper and associate director Tom Smith discuss how and whether reform is being helped or hindered by the Darzi Review and ongoing BMA-Government rows.

TS: This week we’ve taken different stances on the Darzi report. You described my view (www.healthpolicyinsight.com/?q=HPTDarzi) as "optimistic"; I feel you (www.healthpolicyinsight.com/?q=node/94) are being cynical. You see centralism throughout, I see the chance for localism and professional innovation to flourish. I sent you an email earlier this week suggesting we talk about it in this week's Colloquia. I thought your reply was a bit cheeky: "I look forward to finding out why I'm wrong".

I am optimistic, because there are real signs that Darzi has been on a journey. He has listened and, in response, set out a challenging agenda for clinicians to shape the development of healthcare. This might involve new nurse-led organisations providing care. It could be federated GPs, joining commissioning budgets and working with consultants to develop new care pathways. It might involve consultants contracting with GPs in new ways. Some have suggested consultants could become partners in new collaborations with GPs. I see an opportunity for a period of exciting innovation, similar to but going further than the period that followed the introduction of GP fundholding.

AC: I don’t know Lord Darzi’s starting position, so I’m not able to judge whether he’s been on a journey. The point I was making is a more basic response to the actual document and the Constitution.

I still think that in terms of hard content, there was not much in High-Quality Care For All that is new. Many of the ideas on integration seemed to have been culled wholesale from NHS Alliance’s ‘In Sickness And In Health’ document, or to already be around in practice somewhere anyway.

As a result, the rhetoric of the document becomes a focus. And its rhetoric is more clinically friendly and less managerial, as Secretary of State Alan Johnson promised in his speech at the NHS Confederation conference. There’s nothing wrong with clinician-friendly rhetoric (or with being cheeky).

TS: There you go again, flashing that cynicism of yours. I think the report does add something new. It listened to the views of groups like the NHS Alliance, even the BMA, the plans from the Royal College of GPs and has taken on board a view that it is difficult to innovate in the NHS because clinicians do not feel they have the power to change services.

The rhetoric in the Darzi report was about ‘empowering doctors’ and I do think that at this stage, they just remain fine words. But there was real content in the report about the means by which clinicians might play a greater role in the development of services. The requirement for PCTs to support PBC is one of them. The really new thing about the Darzi report was that it actually succeeds, I think, in laying out a non-political reform agenda in which clinicians are cast as agents of change.

AC: But how genuinely locally-owned are the SHA Darzi plans? In your British Society of Gastroenterology role, maybe you’ve had feedback from your members about this?

TS: Gastroenterology wasn’t one of the areas being reviewed and we have exchanged letters with Darzi about the need to review GI bleeding services, in particular. He has been very supportive, and hooked us up within the NHS to work out how this might happen and how clinicians would lead the change process. We have a tool-kit for reviewing services. We are trying to form multi-professional networks for GI services locally and reorganising ourselves to support this. I absolutely believe that Darzi is serious about localism.

AC: If they really allow local innovation, based on evidence and local needs, that could be fantastic. If SHAs become the outposts of the DH in centralising terms, I think that could be problematic.

TS: I agree, and you might end up being right. I am not convinced by how keenly the Darzi vision of clinical engagement is shared with the DH. I sense a difference of emphasis between our two health ministers. On the Andrew Marr show yesterday, when invited to slag off the laggard medical profession, Darzi declined. Do you think Ben Bradshaw would have?

Last week, you suggested Ben Bradshaw suffered from political Tourrettes (www.healthpolicyinsight.com/?q=node/100), and he is the political sponsor of the primary and community care strategy. His voice can be heard when the document talks about 'holding people to account' for quality, which sounds a bit threatening, while Ara Darzi's tone is supportive, though challenging, setting people free to concentrate on quality. Which is the authentic voice of the Department of Health?

AC: It reads badly throughout, like any committee-written document. Apparently there were a total of over 50 authors …

TS: Perhaps it’s good-cop, bad-cop. The Darzi document creates opportunities for clinical innovation and a financial mechanisms to support this - while the primary care strategy talks about the importance of commissioning on the basis of quality, emphasising that this will be monitored, financially rewarded and failures punished.

I hope that the personalities of our health ministers ultimately doesn't matter. The Government needs to be dissuaded from the temptation to fill in the detail of its own vision. It wants collaborative working, clinical innovation, integrated care and competition over quality. Let local areas interpret this. If you define something you kill the many variants that might have developed.

AC: One of the causes for my concern is the issues around foundation trusts. This re-emerged in David Nicholson’s speech to the Confed (www.healthpolicyinsight.com/?q=node/40). FTs are not perfect, as Alan Maynard has pointed out (www.healthpolicyinsight.com/?q=node/61). But their autonomy, which was the point, has caused frictions and developed a sense that they’re a bit of a pain for the DH. Yet every one of the ‘double-top’ performers rated by the Healthcare and Audit Commission Health Check is an FT, and FTs are towards the top of rankings.

The personalities of ministers do matter, whether or not they should. They affect decision-making. Think about Alan Milburn’s style.

TS: I think you’re right that personality of the minister matters, but my point is that they shouldn’t be close enough to clinical services to stamp their personality on it.

Sometimes I think that policy develops through a battle to impregnate words with meaning. Within our politicised service, this is really where the ministers influence the meaning of words. I would like terms like ‘integration’ to be interpreted locally.

‘Integration' is interpreted in different ways by different groups. I worry it will suddenly becomes synonymous with a single model that is produced in guidance from the Department of Health.

AC: Like polyclinics?

TS: Absolutely.

Instead of innovative connections between primary and secondary care, integration will essentially become defined horizontally - as GP practices coming together into polyclinics - and vertically as, foundation trusts offer services in community settings.

If that becomes the case, it will limit the kind of innovation we saw develop from GP fundholding - total purchasing pilots and the like.