The initial proposals made by the Trust Special Administrator to close Lewisham A&E created disbelief and dismay among local GPs and other community leaders. In particular Lewisham CCG board, on the verge of gaining statutory status, felt disempowered and impotent as local provision in their deprived area faced an unsolicited cull. The campaign plus the threat of legal action from Lewisham Council seem to have resulted in a partial stay of execution. Jeremy Hunt has announced plans to downgrade, rather than close, the unit.
In North Yorkshire, because of at least six successive years of notional overspend, we went through an expensive strategic review process which recognised the view that the national funding formula unfairly disadvantages North Yorkshire and York. Recommendations, however, centred on shifting work into the community through service redesign and closure of potentially 200 hospital beds.
Locally, our financially robust Foundation Trusts argued that they should not be the ones to take this hit. In particular the smaller community hospitals seemed vulnerable. Unlike South London NHS Trust, the North Yorkshire Trusts are financially robust despite the PCT overspend, so fortunately the strategic review appears to have been shelved, but this might only be a temporary comfort.
The Lewisham experience is being seen as a test case in the early stages of the new commissioning arrangements. It appears that the Health Minister has pulled back from issuing a warning shot to indebted Trusts about the way central powers might be exercised. But there is a concern is that he’s simply waiting for GPs on CCG boards to do the dirty work for him where necessary.
GPs will be hit first
As a jobbing GP, my concern is that the consequences are not adequately considered, and the reverberations will hit primary care first. General practice, as ever, will be expected to pick up the slack - and the bill - when cuts are made. It is vital that changes that create savings are implemented in an integrated and thought-out or ‘joined-up’ fashion in order that new options are created when aspects of secondary care are decommissioned.
The big question in North Yorkshire is whether the CCGs will be given time to achieve this - such integrated changes are time-consuming and complex to create, and our financial position is challenging to say the least. With a track record of over-spending and historic debt, the CCG locally has been open and realistic about the likelihood of failing to achieve financial balance, not just in its first year but for the next three to five years. This makes it quite a special case. Now we wait and see if Whitehall is up for supporting this endeavour for the long-term, or is simply focused on reducing the bill rapidly at any cost.
Learning from Lewisham
Lessons need to be learned from the Lewisham campaign. Quite contrary to the notion of being part of a ‘defeated profession’, GPs need to appreciate that they are taking the commissioning reins over for very good reasons, and that there is power in this. We need to learn to trust what we know and be prepared to fight hard for it.
This means keeping in touch with local commissioning strategies, paying attention to CCG communications and also commentaries from other agencies. LMCs will be central in a monitoring function. In North Yorkshire we have a strong and active LMC that updates its constituency frequently. In addition, much attention has been paid to how best to serve various functions in liaison with the CCG.
We need to grow in our ability to repel top-down decisions through a range of activities such as lobbying, petitioning the public, and learning about various platforms for public communication including social networks. Developing relationships with local, trade and national media, and employing PR experts, will be key skills in local health service campaigns. We need also to forge alliances with others such as our local councils or third sector organisations - highlighted in the Lewisham case where the Mayor waded in.
In particular we need to ensure that the general public remains an ally and does not drift away from us on a stream of negative press about GP greed, laziness and vested interest. In Lewisham, 34,265 people signed the petition to save the hospital, and an estimated 25,000 campaigners took to the streets. The Save Lewisham Hospital campaign website is a good place to start looking.
In the coming years we must be acutely aware of the risk of being seen as the agents responsible for dismantling the NHS. In North Yorkshire we have been cautious about running to the press but when we have perceived threats to primary care delivery (from over-stringent thresholds or restrictions on referrals, for instance) the LMC has found it a useful exercise in ‘jump-starting’ negotiations. Currently, the public is more or less aware that the NHS is under threat. It’s up to us to make sure that we don’t get scapegoated erroneously for either the privatisation agenda, or cuts.
The BMA’s consideration of asking patients to support a boycott of private health providers was an interesting early example of an attempt to create a bridge between doctors and patients in the fight to save the NHS. Another invaluable resource is the Keep Our NHS Public website. We even now have a political party to get behind that is active in campaigning to oppose the commercialisation of the NHS and expose the political and corporate corruption behind this process. The BMA has a difficult task in treading the line between being pro-actively radical and catering for the needs of the intelligent, opinionated, heterogeneous and sometimes reactionary people it needs to represent.
But I think this is an important time if ever there was one to join the BMA, follow its arguments and also to pay attention to what the GPC is saying. Try to get along to one of its regional roadshows and get informed. Lewisham demonstrates that we can stand up for ourselves and for what we know is right for our patients and communities.
Dr Andy Field is a GP in York. He is also a member of North Yorkshire LMC but this article does not reflect the views of the LMC.
