Has Lord Darzi left general practice a valuable legacy?

Posted on September 9, 2009. Filed under: GP-led health centres, News stories, Polyclinics |

Pulse | 9 September 2009

Debate_Yes_stampPolysystems – with a polyclinic at their hub – are just one way in which Lord Darzi’s vision of high-quality, joined-up care is becoming reality, says Dr Tom Coffey

 Lord Darzi’s legacy has been to raise the aspirations of healthcare providers across the UK. His vision puts quality at the heart of the NHS and emphasises clinical leadership as a key driver for making it a reality, particularly through local pathways that can help bridge the gap between primary and secondary care.

There is now a greater focus on helping people stay healthy, on long-term conditions and on mental health. These are lofty ambitions, but has his vision of high-quality care for all made a real impact?

As GPs, we all aspire to provide healthcare that is as good as it can be. One mechanism Lord Darzi has recommended to support this kind of aspiration is the publication of quality accounts.

From 2010, PCTs and acute trusts will provide the public with detailed information about their clinical performance for the first time. Healthcare has sometimes been slower than other service industries in using its own data to drive improvement, but this is changing rapidly, as the quality accounts plans show.

Evidence-based medicine was once enormously controversial but is now accepted as a standard part of practice. In the same way, I predict that the quality agenda will transform how we look at our own roles and deliver services for our patients.

Another positive from Lord Darzi’s reforms is their emphasis on clinical leadership as a key driver of change. His ideas were developed from 10 local plans across the UK, built on contributions from hundreds of doctors and other NHS staff. In London, he personally led this work before he joined the Government and therefore, I would argue, the impact of his reforms has been even greater here.

The Darzi reforms strengthen the role of GPs as leaders – making them the drivers of innovation and improvement in care, all based on the needs of our local communities. The clinical redesign of services not only brings those services closer to patients but ensures they are delivered in a way that prioritises quality, especially clinical effectiveness, safety and excellent patient experience.

Already, through our commissioning skills, doctors are developing care pathways built on strong partnerships between GPs, specialists and social care providers. In London, this has been realised through the development of polysystems, based on the hub-and-spoke model and supported by a primary care-led polyclinic hub at its heart.

The strengths of traditional general practice will be maintained – patients can keep their long-standing relationships with GPs but can also access urgent healthcare close to home without an appointment and with more flexible opening times.

Lord Darzi’s vision of a high-quality, locally led NHS with a focus on wellbeing as well as health has already made a significant, positive impact.

Management of long-term conditions will be transformed by commissioning locally designed multi-professional services in the community, linked to social care providers. Suitable outpatient work, diagnostics, minor operations and urgent care will also be provided in the polysystem. Co-location of professionals will foster improved communication and a streamlined, joined-up service.

In London polysystems are up and running in some parts with plans to cover the whole city. I hope all my NHS colleagues will join me in shaping the future, so that this legacy can continue to deliver solutions for patients and professionals alike.

Dr Tom Coffey is the clinical director of Healthcare for London’s polyclinics project and a GP in Tooting, south London

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Debate_No_stampHaving a clinician in Government should have brought evidence-based, patient-centred healthcare. What we got from Lord Darzi was centrally imposed policy, says Dr Grant Ingrams

Lord Darzi’s appointment to Gordon Brown’s Government Of All the Talents (GOAT) should have heralded a new era of enlightenment within the NHS. A practising clinician at the heart of Government should have brought health policy in touch with the delivery of care at the level of individual patients.

It should have led to evidence-based, high-quality, cost-effective healthcare. Unfortunately, it very quickly became clear that this was not going to happen.

So what went wrong? Was he the scape GOAT or just acting the GOAT? First came his interim review. Although only reflecting pre-existing Government policy, adding his name legitimised the commercialisation of general practice.

The genie is now out of the bottle and this act of vandalism on the NHS will gradually undermine general practice.

Lord Darzi repeatedly stated that change should only be implemented if evidence-based and with local agreement. He told John Humphreys on the Today programme that the opinion of local people would be respected ‘absolutely’.

He repeated this mantra in evidence to the Commons health committee. He also said that every change would be to the benefit of patients. The enforcement of a ‘GP-led’ health centre on every English PCT broke both pledges.

Did he really have no idea his ‘voluntary’ policy was being enforced, with resistant PCTs being bullied by SHAs to comply?

So what is the evidence behind this Darzi policy? There is a well-demonstrated direct relationship between the number of GPs in an area and its health outcomes. But this does not mean bringing any doctor into an area will automatically improve outcomes. The US academic Professor Barbara Starfield has shown high-quality and cost-effective healthcare requires doctor-patient continuity of at least three to five years.

The usually reticent RCGP has openly criticised the Darzi centre policy, describing it as ‘Martini’ medicine – any time, any place, anywhere, any doctor. The public repeatedly reaffirm they value continuity of care with their GP over and above everything else. The BMA had no problem in gaining 1.2 million signatures in less than two weeks proclaiming Lord Darzi’s plan was wrong.

Commercialisation of other parts of the NHS, for example through introduction of Independent Sector Treatment Centres, has resulted in higher costs for, at best, the same healthcare. Commercialisation of general practice will have the same result – the independent sector is always going to focus on short-term profits. As commercialisation is introduced, more money is lost to non-clinical expenses – as high as 35% in the US.

The final Darzi report expresses many ideals we would all aspire to, but also contains further threats to general practice. It calls for the removal of the MPIG without understanding that it frequently funds additional services. It calls for greater choice, but healthcare is not a commodity and patients are not consumers. Choice benefits wealthy, educated populations at the expense of others and increases costs and decreases quality.

Finally, it encourages the development of a target-driven culture for general practice. This will have unintended consequences, which are not always desirable.

Lord Darzi should be remembered as being the first, and I hope last, minister to misuse NHSmail for spam – sending politically motivated spin. He is responsible for starting the wanton destruction of personalised general practice.

There is an old adage: ‘Any surgeon knows how to operate, a good surgeon knows when to operate, a great surgeon knows when not to operate.’ Lord Darzi should not have operated on general practice.

Dr Grant Ingrams is secretary of GPC West Midlands and a member of a consortium running a GP-led health centre

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