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So, has Dudley really been an NHS success?

Lately Patricia Hewitt has seemed obsessed with Dudley, citing it repeatedly as a beacon of success in the NHS. Go and see it for yourself she told Pulse at one meeting. So we did. Helen Crump reports.

Just over a decade ago, Dudley was presented with a typical NHS conundrum. It was given the go-ahead for a brand-new, £160 million hospital, built via the private finance intitiative.

Russells Hall would have the latest diagnostic and treatment facilities and would vastly improve care for patients.

The only problem was it would have have 70 fewer beds than the hospital it replaced.

Unless services were redesigned to help keep people out of this sparkling new facility, Dudley Beacon and Castle PCT was warned by its strategic health authority in 2003, there would be major difficulties.

Thus was born a strategy for treating patients with chronic and long-term conditions in the community which has been repeatedly hailed by Health Secretary Patricia Hewitt since her visit to the region earlier this year as a model for the NHS.

The strategy borrows large chunks from the 'pyramid' model developed by US health care provider Kaiser Perman-ante. First, patients with chronic illness who are most at risk

of hospital admission are

identified.

Nurse practitioners provide care 'pathways' in areas such as heart failure, elective care and palliative care for these patients and a nurse consultant acts as lead clinician.

Crucially, GPs are meant to refer patients with long-term conditions, where possible, to these specialist teams or assertive case managers rather than to hospital.

Dr Steve Cartwright, a GP in Dudley and professional executive committee chair of the PCT, says GPs were involved right from the outset and allowed to critically appraise the plans to ensure their support.

He says: 'They said get on and do it because they recognised the problems of having a new hospital with fewer beds.

'They didn't want their patients stuck in corridors. They didn't have the resources themselves but there was capacity in the nursing teams.'

Enhanced service money and a pump-priming fund got the service, which now costs £750,000 a year, off the ground in late 2004, just before the hospital opened.

Within six months, emergency admissions dropped by 11 per cent.

For heart failure the figure was 16 per cent.

But the scheme is still very much in its infancy and GPs in the region are by no means fully on board yet.

Dr Tony Blackman, Dudley LMC secretary, says: 'It's a culture change. For years, GPs have always referred doctor to doctor. The problem is getting local practitioners to accept that others can help them to manage the patient.'

Dr Cartwright believes the issue of getting GPs to refer to the nurses has been largely overcome by recruiting nurses from an established pool who were already well-known to the GP community.

But other GPs are still reluctant to pronounce it a success until it has a longer track record.

Dr Joginder Pall, a Dudley GP who has used the heart failure service, says it has relieved some of the burden on GPs' time.

He says: 'It's difficult yet to tell how much impact it has had on our daily lives, though in the long-term it should be helpful.'

And Dr Blackman says that even though it is working now, 'there's no guarantee it's going to continue to work'.

Some of the wariness stems from the restructuring and financial problems that continue to bedevil the NHS. After the success of the first six months, emergency admissions have since begun to creep up.

Dr Cartwright attributes this in part to Payment by Results, which acts as a disincentive for hospitals to co-operate because they lose money if patients are treated elsewhere.

'That's a stress in the system which just means that we have to redesign again,' he says.

Continuing funding is another problem on the horizon, according to Dr Blackman.

He says the initial success of the scheme should trigger more resources from Government and that efficiency savings should be retained, not taken away to balance debt in the acute sector.

He says: 'The health service runs on goodwill. Goodwill is at risk. It's all very well Mrs Hewitt saying Dudley got it right but she won't put any more money into Dudley to do it.'

Dr Cartwright concedes that budget constraints on the PCT have 'sapped morale', but believes continued funding is available in the form of secondary care budgets accessible through 'mature commissioning'.

The other threat is the planned merger between Dudley Beacon and Castle PCT and its neighbour, the more affluent South Dudley PCT, which has its own version of the long-term conditions model.

Although Dr Nick Plant, South Dudley PCT PEC chair, says the PCTs are well placed to merge their schemes, there is an evident tension.

'Dudley Beacon and Castle PCT has a much better publicity machine,' he says.

'We're doing exactly the same thing and the emphasis is changing as we're coming together to being a Dudley model of care, not a Beacon and Castle model of care.'

Dr Plant is also more forthright about the potential for money problems to influence all policies, including the long-term conditions scheme ­ predicting a 'dire' financial year ahead for the NHS.

The upshot is that, for all Hewitt's proselytising about the Dudley initiative, its future by no means secure.

It is another typical NHS conundrum that the threats to a scheme praised by the Health Secretary and generally felt by local GPs to be a success, can all be traced back to Mrs Hewitt's Richmond House office.

hcrump@cmpinformation.com

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