This year will hold momentous changes for the NHS as the reforms are rolled out – but perhaps the biggest opportunity of all which should be grasped is that of intelligent reshaping of services. It matters for surgeons as much as for managers. Let me explain why.
Nelson Mandela has made a huge impact across the globe. His struggle to end apartheid will surely earn him a place in the history books as one of the great political figures of our time. While he has been a source of political change for millions of South Africans, you might struggle to immediately guess why, for me, he has also recently embodied medical change.
There has been much speculation about the health of the former leader and in December, following a lung infection, he underwent removal of gallstones by a minimally invasive technique. Before the late 1980s, this procedure was very painful, as surgeons had to make a big incision across the abdomen that looked like a sabre slash. Recovery time could be anything between six weeks and three months.
Developments in surgery have now put an end to that. The surgeons treating Mr Mandela used endoscopic surgery, which allows people to be home within 24 to 48 hours, in most cases recovering within a week.
Alongside the greater availability of short stay surgery, patients also benefit from surgeons who specialise in complex surgery. For certain procedures and conditions, such as stroke, certain types of cancer and abdominal aortic aneurysms, concentrating specialist surgical services into fewer, larger centres of excellence can improve outcomes with simultaneous improvements in training and education. A surgeon carrying out a large number of similar operations will gain more experience than a surgeon who carries out just a few.
Six years ago, Lord Darzi published an important paper on the clinical case for change in surgery. Saws and Scalpels to Lasers and Robots – Advances in Surgery called for a move away from the District General Hospital towards an 80/20 split between local day surgery/complex centralised surgeries. Such a concept is perhaps too radical, but we should be moving towards greater centralisation and I believe we are now better placed to bring about these clinically necessary changes than ever before.
A greater number of my medical colleagues in other royal colleges have made a public stand on service change, which is likely to increase as clinicians become more involved in commissioning. Importantly, ministers and shadow ministers seem also to be thinking along similar lines. However, as we get closer to the 2015 election, some changes will inevitably get swept up in election campaigning. 2013, therefore, has to be the year when clinically necessary service change happens if it’s not to be kicked into the long grass yet again.
To an extent, health service staff must take some responsibility for slow progress. Too many reconfigurations have failed to win the support of doctors, nurses or the public. Consultations have sometimes been a loaded tick-box exercise designed to secure token support, rather than engage in a genuine conversation with the public. We must ensure the public understands the substantial clinical benefits that can be achieved, while addressing natural concerns regarding the availability of emergency care and transportation issues.
I, of course, recognise that even where there is an undeniable clinical case for change, some opposition may still occur, and in such circumstances, brave leadership from medics, managers and politicians is needed. The Royal College of Surgeons has been strongly supportive of the Safe and Sustainable review’s approach to centralising children’s heart services. The public consultation was the largest undertaken by the NHS and the review has been thoroughly scrutinised by three Appeal Court judges, who ruled that the process was fair, lawful and proper. It is hard to believe the Independent Reconfiguration Panel (IRP), chaired by my colleague Lord Ribeiro, will not agree with the basic tenets of the review. If the Government do not back change when the final recommendations from the IRP are published in late March, then we must question what progress other changes can make given the overwhelming clinical case in support of Safe and Sustainable.
2013 will be a significant year for health with the implementation of NHS reform, the Nicholson challenge, and the Mid-Staffs public inquiry, to name a few events. But the greatest health challenge facing us is service redesign. Without it, many of the inherent problems in the system are likely to continue.
There are no fewer than four major reconfiguration decisions this year: children’s heart services, South London Healthcare NHS Trust, as well as likely changes to the services available at Peterborough and Stamford Hospitals NHS Foundation Trust and Mid-Staffordshire NHS Foundation Trust. Our national leaders must support the NHS and back clinically justified changes but not those driven solely by financial imperatives. 2013 needs to be the year patients, politicians, clinicians, and managers come together to support historic change in the NHS and create a long-lasting legacy for all of our population.
Professor Norman Williams is President of The Royal College of Surgeons