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KERR AND KERR:
CAN THEY FIX IT?

By Gerry McCartney
Contact the author via Chris Johnstone by e-mail at christopher.johnstone@ntlworld.com

A review of “Building a Health Service Fit for the Future” (Prof. David Kerr, May 2005)

Health service reorganisation has been back in the news of late following publication of David Kerr's review of health service organisation. The timing of this has always been somewhat suspect, with it informing the debate only after the general election and the decision to dissolve Argyll and Clyde health board.

Putting this aside, (David) Kerr has conducted the consultation that health boards should always be doing, and has produced a clear list of the real public concerns present. Many of these centre on the provision of local quality health services as part of a co-ordinated, universal NHS.

Kerr does dismiss some concerns as, 'scaremongering' and 'fanned by local media', but these concerns are real when comprehensive maternity, medical and surgical services are withdrawn from some areas. What needs to be answered is why services could easily be provided safely 5 years ago, but not now.

In essence, Kerr is required to justify these service cuts on clinical grounds. This is opposed to the widespread perception that political incompetence, the narrow self-interest of royal colleges over the needs of the NHS, or financial constraints have been the main drivers.

To his credit Kerr looks beyond the five year political horizon to identify the wider issues that are set to impact on NHS Scotland. These are demographic changes (for patients and staff), the European Working time directive, the impact of new contracts, advances in technology & communication, and growing health inequalities. He has also enlisted expert and lay help to tackle these issues, and his work is supported by a number of supplementary reports on each section.

Reading the report can be a little challenging however. Once you can tell your CHP from your MCN, and your GPwSI from your ICT things do become clearer.

His vision is of quality local services, improved waiting times, use of new technology, a reduced health gap between rich and poor and value for money. Central to this will be an improved, broadened primary care service, with resources channeled from secondary to primary care through CHPs. Delayed discharges and inappropriate admissions are targeted, highlighting those patients who require the longest periods of in-patient care. He separates 'scheduled' from 'unscheduled' care, and provides a useful breakdown of the services a District General may or may not provide in the future.

Campaigners will focus on the difference between 'Level 2' and 'Level 3a' services. This is the difference between a 24 hour medical and surgical admission unit (the traditional DGH model), and the newly defined 'intermediate care' unit. The move of many DGHs from 3a to 2 as well as the changes to maternity provision were the original sparks that led to the commissioning of the report.

Some suggestions will raise eyebrows amongst our secondary care colleagues. Evening ward rounds and weekend routine operating are suggested as are the use of dedicated staff for emergency admissions as opposed to elective admissions.

Some factors and ideas have not been mentioned, such as the role of the royal colleges in dictating the centralisation of some services and the use of shared overnight consultants between units (staffed by junior doctors) to sustain services. The role of non-surgical specialties also seems to be have less analysis.

His proposals endorse an increased commodification of health care with acceptance of tariffs, DTCs (diagnostic and treatment centres) and use of the private sector. The health economics report does not analyse this proposal in detail, but it is adopted nevertheless. This does not sit easily with his commitment to tackle health inequalities and will be seen by some as a green light to the Scottish Executive to pursue the agenda started by former BMJ editor Richard Smith and continued by John Reid and Patricia Hewitt south of the border.

He also suggests that his proposals would be cost neutral (although calling for a devolution of resources into primary care via community health partnerships). This will disappoint others who point out that the extra resources provided to the NHS since 1997 have almost entirely gone into the wages of doctors, into paying pharmaceutical bills and into PFI/PPP contracts (cost which of course are set to rise inexorably over the next 30 years, and will create a huge capital problem at the end of the contracts).

It also calls into question whether the lack of support services that delay discharges and cause those patients 'off legs' and 'failing at home' to be admitted, will be given larger budgets. It raises the same questions that 'care in the community' raised 10 years ago. Is it care in the community, care by the community, or simply privatised care in another institution outside the hospital grounds? A proposal to prevent admission of an ageing population will require extra resources, and it is only when resources flow to primary care and social work that this could be achieved.

Whether the report will meet these challenges will only be known in retrospect, and that is of course dependent on whether Kerr's proposals will be implemented. The 'cost neutral' pledge may make this more likely. The real test may be whether the public tolerate the downgrading of some facilities and privatisation of others, or whether the new CHPs can be made to work with adequate resourcing and co-operation between local authorities and health boards.

Other hoolet online articles by Gerry McCartney can be found at:
hoolet edition 45 - Kerr²
hoolet edition 44 - REVIEW: NHS plc - THE PRIVATISATION OF OUR HEALTH CARE

hoolet is the magazine of RCGP Scotland. It is supported intellectually, financially and emotionally by RCGP Scotland.

This issue maintained by Robert Hallam.