Colloquia: talking about Darzi

Health Policy Insight’s editor Andy Cowper and associate director Tom Smith discuss whether the Darzi review can  “lead local change from the centre”

AC: So Tom, your latest Health Policy Today  suggests that "the publication of the Darzi report, with its focus on local innovation and opportunities for clinicians may be able to move debate on from the current political impasse". That's pretty much tantamount to optimism. What makes you optimistic about this?

TS: I realise my optimism is against the grain.  In today's Sunday Times, Simon Jenkins takes Gordon Brown to task for his centralism and dismisses any move to localism as false.  He must mean the Darzi review when he says, 'there are rumours that Brown will pretend to decentralise health...yet again'.

I haven't always been optimisitic about the Darzi review.  At first, I was suspicious about politics of the review and sceptical about the commitment to localism.  I remembered Ara's intervention in the Harlepool fiasco, where he was pushed to the north-east to engineer an outcome that ensured Peter Mandelson kept his seat.  Interestingly, Darzi refers to the Hartlepool fiasco in a profile, also in today's Sunday Times.  He says he lost sleep about becoming a minister because he later realised he was used as "a pawn" back in 2004.  

A year ago, I questioned whether Darzi's Review was able to take us down the road of localism.  The interim report that was published contained the sentence, 'we will lead local change from the centre' - not the most libertarian of statements.  But again, I think Darzi has been on a journey and has come to the view that the way to move the NHS forward is for the centre to create the conditions for local change.

On BBC Politics Show, Alan Johnson said a very interesting thing: (I paraphrase) "Darzi has shown us actually that we have the mechanisms in place to rely on local accountability without the need for central and top-down targets".  It didn't sound like a line to me.

Darzi has withstood an awful lot of criticism this year, but during the political angst there has been a very helpful period in which groups of clinicians have begun to think about the health service could be better organised.  We've seen the RCGP talk about Federated Practices.  There is a move now to bring GPs together in larger groups: that wasn't around a year ago.  Despite what you read about the BMA, I know there will be a lot of hard work going on, sketching out possible options for changing practices. In the report tomorrow, I expect to see some support for the idea of large commissioning groups and the development of integrated primary services.

AC: As we’re now meant to call polyclinics. Although every London PCT has gone for one, the message does appear to be (again, we’re putting faith in the leaks here - The Observer’s bucket of leaks looked pretty full) that polyclinics as originally understood are more for cities, and that the integrated care organisations will bind or confederate existing GP practices.

The silly bit about polyclinics was that even if the national need was for new buildings (and in some areas, it is, because the primary care estate is so crap), by saying next to nothing about ownership arrangements, you instantly alienate pretty much all GPs – the GMS ones who have capital in their practices already are obviously amenable to some risk; and the many who want to become partners but can’t find vacancies in their preferred areas might well have been willing to sign into long-term deals involving some kind of ‘sweat equity’ to buy their way in through reduced fees in the shorter term. Surely some economic gnome could have come up with some of that?

Anyway, I reckon from the recent Confed conference that there’s a £250 forfeit for any DH employee who uses ‘the p word’.

TS: The polyclinic row demonstrated that Darzi (and perhaps the Government) do understand that the outcome is important and the process less so.  They have been villified for backing away from the polyclinic word, but I think it shows intelligence.  Whether it is through co-location or federation, what matters is that GPs and others are thinking through how to expand services and better integrate them.

AC: Integration is of course always a good-sounding word, but it does depend on who is driving the integration. And also, to shamelesly steal Nigel Walker’s adaptation of Walter Luetz’s 1999 Millbank Quarterly five laws on joint working:
1. You can integrate some of the services all of the time and vice versa, but you can’t integrate all of the services all of the time
2. Integration will cost before it pays
3. Your integration is my fragmentation
4. You can’t integrate a square peg in a round hole
5. He or she who does the integration calls the tune

With polyclinics, the original thinking seemed to be the DH going, ‘OK, we’re the customer and we’re going to dictate what we want to buy’. And the producer interest didn’t respond to that idea of integration, as we have seen.

Moving on with the leaks, I reckon there is a possibility (with Neil Diamond playing Glastonbury in the background, appropriately) that the Darzi Review is going to be a ‘Greatest Hits’ with very little that’s new.

It’s been clear for a couple of years now that social enterprises and not-for-profits have been able to offer the NHS pension, and do so. Scores of GP out-of-hours co-ops and social enterprises do already. Nurses already have the right to request transfer – Central Surrey Health being the obvious example. This is basically about the commissioning-provision split, and presumably the message here from the Department is to get PCTs to give their provider aspects a helping foot.

TS: I think it is genuis to open up the possibility of nurses (and other clinicians) forming groups to deliver services.  Solving the pension dilemma is very important.  We could see consultants start to group together and sell their services to PCTs.

There are a lot of ideas around at the moment for changing services - did you see the HSJ typology of 'integrated models' a couple of weeks back?  I think it was drawn from an HSMC report, All together now?  I think it's right that Darzi is playing to the entrepreunerial clinician.

It may not be popular to say so, but I was quite a fan of the GP fundholding experiment and, in particular, the collective models of commissioning that it spawned.  There was a lot of experimentation and different models in operation at that time and it's a shame that these were never fully captured - through the LSE and King's Fund did document some.

The idea of social enterprise will be attractive to Fabian wing of the Labour Party.  It chimes with the idea of professionally-led control and localism.  And best of all, it gives a new dimension from which to deconstruct some of the scare-mongering around the impact of the private sector.  I think I wrote about it on HPI a week or so back, that  papers like the Newcastle Gazette were saying traditional general practice would disappear across the north-east.

The emphasis on social enterprise helps to explain that this is about encouraging innovation and clinically-led change.

AC: There has been some proper shroud-waving bollocks talked of late about the threat to general practice. If GPs have this fantastic relationship with their patients with long-term conditions, then surely they won’t be threatened by an impersonal polyclinic? I’ve got an ongoing (commercial) relationship with my local butcher and his product quality and value for money are fantastic – so I’m not going to spend my hard-earned on bad-quality badly-presented supermarket meat. Even if the supermarket is open 8-8.

And the rhetoric about the private sector is fairly specious in an area of the service that is virtually all provided by small GP-owned and run private businesses. There was some recent comment about how impossible it would be for a practice or consortia to put together a tender for a new centre, which slightly made me lose the will to live.

Again, innovation and clinically-led change sound lovely. But can we measure clinical leadership effectively, if even a super-surgeon like the Good Lord Darzi himself got conned over Hartlepool as you outlined earlier?

And how confident are you that what we’ll see in Darzi doesn’t just replace centralism of the DH with 10 slightly regional centralisms of the SHAs?

TS: The reason I'm optimistic is because I can now see how the Darzi review can move us on from this political impasse.  It's been a long time.  Thinking about it, this is the fifth year of lazy stereotyped debate about the future of health policy.  In my view, the government were often guilty of stoking this fire.  It’s exciting that we could now start talking about how best to support clinically-led change.

AC: Do you reckon London SHA is going to redisorganise (TM Alan Maynard) its PCTs? And probably more importantly, shut any hospitals? Have SHAs got the political cojones to take the inevitable shit that will come from closing things?

TS: I think there will be some closures, but the scale will be smaller than anticipated.  Darzi has said that facilities will not close until replacement services are in place.  That’s a big promise, and one to which local doctors and patients will hold them.  The process of change is always slower than we expect, and it is possible that over next two years (in the run-up the next election) will see the development of local plans and some significant steps towards them.  As polyclinics develop over the next year, they will have an impact on current GP practices.

So I think it’s likely that practices could come together.  Is that the closure of practices?  It depends upon your perspective.  But when it comes to the big stuff, I don’t think we’ll see hospital services close for a couple of years.  Up until the election we are likely to see the development of ‘alternative’ services.  With these in place (and an election out of the way), we may then see some change in the map of hospitals in the capital.

I don’t think there is an appetite to change the PCT structure though that doesn’t mean they won’t change in important ways.  It now looks as though Nigel Crisp was right – PCTs look set to begin the journey of divesting of their provision function.   When this is complete, it may well be logical to look again at PCTs.

I know it seems naff, but one cosmetic bit of policy I quite like is to move away from PCTs with long names towards something simple, so in my area it would be Camden NHS.  I just think that does what it says on the tin.  The local public will then be more clear about who is responsible for the quality of their local NHS.
PCTs have a huge and confusing agenda – supporting the development of local enterprise, bringing GPs together in new collaborations, introducing world-class commissioning, working with LiNks.  They’ve got to do something called ‘market management’, which doesn’t sound at all clear.  

On top of all this, it looks as though the Constitution is going to make PCTs responsible for the fair introduction of NICE guidance.  On the BBC Politics Show, Alan Johnson accepted that it is already the case that PCTs should implement NICE decisions, but now patients will have a right to ensure that is the case.  The government are giving the green light for local patients to pressure PCTs.  

AC: The leaks about PCTs having to fund NICE advice (or explain why not to their population) are interesting. Two reasons: one, it seems to heap loads of pressure on NICE to speed up appraisals, and by implication to approve a bit more - which the pharmaceutical industry will be quite happy about.

Two, it also takes the focus of the arguments around new drugs back towards NHS funding them faster, and away from investigation of whether they are good value for taxpayers’ money – or “trinkets of frivolous utility”, to borrow Adam Smith’s lovely phrase. The implication of this is that all new drugs should be funded. Where’s my online share purchasing website, and how are pharma doing tonight? Because they’ll be up tomorrow on the back of this.

So NICE will need some serious extra resources: Michael Rawlins’ interview with BBC News Online (http://news.bbc.co.uk/1/hi/health/7476222.stm) is bullish that they’ll get them. Two: because if PCTs are honest, they will say “because we can’t afford it” a certain amount of the time. That’s the reason now, and it’s led to the top-up review Nick Timmins wrote about (www.healthpolicyinsight.com/?q=FirstThoughts)

TS: I think this could be a really interesting issue.  The new constitution suggests that PCTs will be under pressure from their population.  At some point down the line, if the PCT cannot secure all the resources it needs, then down the line, the PCT may have to begin to engage with their politicians about local choices not to provide everything in order to provide something else.  I think this issue will take some time to play out.  On the horizon it may be, but it will become an increasingly important question.