Reflections on Leadership, Lessons and Legacy
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Healthcare for London Reflections on leadership, lessons and legacy Hannah Farrar Alastair Finney David Griffiths Christine Kirkpatrick CONTENTS Foreword 1 Introduction 5 2 Healthcare for London: Development and Implementation 9 3 Case Studies 40 4 Lessons Learnt 97 I first met Ara DarzI in the summer of 2006, when he had just begun to put ideas 5 Conclusion 142 together for the review he named Healthcare for London: A Framework for Action, which had been commissioned by my predecessor David Nicholson. We put together teams of Appendix 1 – Questions 150 people and engaged literally hundreds of clinicians in this work, but even so, I don’t think Appendix 2 – Biographies 152 either of us realised at the beginning the immense scale of the task at hand. Nor did we realise the level of controversy and conflict we would initiate. References 156 The history of healthcare in London is littered with reviews (the first recorded review was in 1892), many of which have failed, so we approached this challenge with some trepidation. What made this different from its predecessors? First and foremost it was led by a practising clinician with an international reputation who would continue to work in London. Second, the strategic health authority and PCTs in London put significant and sustained resources behind its implementation. Third, its legitimacy was established through the clinical leadership of an extensive consultation and development programme. Fourth, when approaching implementation we insisted on tackling a few priorities properly, rather than taking the easier route of making a half-hearted attempt at everything. There was a powerful case for change in Healthcare for London that continues to have resonance today. There was almost universal support for this case, but of course with significantly divided opinion about what it meant in terms of service change. Nevertheless, a momentum for change was established and improvements began to emerge. Some of these have now achieved widespread recognition through independent evaluation, but just as important to us has been the positive feedback from clinicians and patients across London. This report attempts to describe and reflect on the progress that has been made and the lessons learnt. For me, as the person responsible for healthcare in London, the most challenging point came with the change in Government in May 2010. Healthcare for London had become an election topic and, in the heat of political debate, many of the proposals and ideas became badly distorted. It was caricatured as a ‘one size fits all top-down plan’ and new Secretary of State for Health, Andrew Lansley, wasted no time in bringing all the work on Healthcare for London to a halt via an announcement on national television. >> 2 | HEALTHCARE FOR LONDON REFLECTIONS ON LEADERSHIP, LESSONS AND LEGACY | 3 foreword In my view, it is a measure of the strength of clinical support for change that many of the proposals and recommendations continue to be implemented. But at the time, the Secretary of State’s intervention had a powerful effect. Those clinicians and other leaders who had invested time and energy into making change work were angry and frustrated, whilst cynics who never really believed change could happen were in ‘I told you so’ mode. Those who sought refuge in the status quo either rejoiced in the respite afforded by this decision or derided our efforts as little more than a blueprint in a desk drawer. For my organisation it was a bitter blow, but we were sustained by the many, many clinicians from all sectors who continued to bravely champion Healthcare for London. Especially important were the GPs, who were afforded some legitimacy to continue and became our most powerful allies. What, if anything, has been lost during the past three years, whilst we have been obliged to focus on the mechanics of reform? Was it just another plan or piece of bureaucracy with no cost to London’s patients? The fact is that some people continue to have their cancer diagnosed in A&E because of inadequate primary care and diagnostics; people are still admitted as complex emergencies to hospitals with insufficient consultant cover; acutely ill patients admitted at nights and weekends are still more likely to die in hospitals without 24/7 consultant cover; urgent investment is needed in integrated care for people with long term conditions; some maternity units cannot offer the level of care needed for obstetric emergencies. I could cite many more examples and I do not pretend that we could have solved all these problems but measurable progress was being made on all these fronts – progress that was slowed for a time. It is for our successors to pick up the case for change in London and I have seen for myself how they are aiming to do that in every new clinical commissioning group. I hope this report provides both evidence of improvements to build on and the lessons that can be learnt from mistakes made. Finally, I would like to thank Ara Darzi, whose total commitment to improving quality was enshrined in Healthcare for London and gave meaning and direction to every single one of our working days at NHS London for six years. introduction DAmE Ruth Carnall 1 4 | HEALTHCARE FOR LONDON introduction IN 2006, only 53% of stroke victims in London were treated on a dedicated stroke ward, Recognising the fundamental challenges that most health service providers in London face, less than 1% of patients were offered clot-busting drugs, comprehensive specialist stroke NHS London has also encouraged individual NHS trusts to work more closely with partner services were rarely available 24/7 and rates of death from stroke in London’s hospitals varied organisations, including their new commissioners, to secure the long-term viability of services considerably. In short, the quality of stroke care in London was poor and deteriorating – for London’s population so that patients continue to benefit from sustained improvements in stroke was London’s second biggest killer and the most significant cause of disability. quality of healthcare. However, stroke care in London has since made huge improvements. Twice as many stroke As primary care trusts and SHAs finally hand over their responsibilities for the planning and victims as before are taken direct to a specialist stroke unit, with average journey times by commissioning of health services, the new organisations inherit an NHS in London that has ambulance only 14 minutes, and considerably more patients are receiving clot-busting drugs delivered some profound improvements over the past six years. They also inherit an NHS with than previously, with the rate of thrombolysis in London now higher than the rest of the the scope to do much more in coming years and where there are still unacceptable variations country and any large city in the world. 400 extra nurses are also caring for people who have in health outcomes and unacceptable variations in patients’ experience of the care they receive. had a stroke. All of this has contributed to over 200 fewer deaths from stroke each year in London and is a direct result of Healthcare for London. AImS of the report This report tells the story of Healthcare for London from its inception in 2007 through to The aims of the report include: 2013, through the voices of those closely involved. It outlines the processes used to turn the vision originally described by Professor the Lord Darzi of Denham into a distinct set of n To describe how the Healthcare for London vision was created recommendations and describes how some of those recommendations were implemented n To record the lessons learned by healthcare professionals and managers who went by the health service. through the process and invested vast amounts of time and resources into designing The term ‘healthcare for London’ has become synonymous with the overarching strategy and implementing the vision for transforming healthcare in London since 2007. It is shorthand for the vision outlined n To explore why some clinical changes have been implemented successfully, whilst others in the report Healthcare for London: A Framework for Action and for the programmes of have made less progress work subsequently undertaken to make that vision a reality, including the changes to stroke, n To set out developments that have taken place in London since the implementation of trauma, cardiac and vascular services and for the introduction of polyclinics (or polysystems) the Healthcare for London vision was formally halted in 2010 in the capital. It also led to a range of guidance and other developments in service areas such n To consider next steps, taking into account subsequent and more recent research and as long-term conditions, including diabetes, and urgent care. analysis, and provide a platform for those responsible for the ongoing improvement of Whilst the terms ‘success’ and ‘failure’ are too concrete to describe the many changes health services in London associated with Healthcare for London, there are areas where services have undoubtedly and While the lessons learnt may be most relevant to those working within the health service measurably improved following the introduction of new care pathways based on the report’s in London, many extend to the management of health systems across the UK and vision. There are also some areas where the improvements envisaged have not been achieved. internationally and have generic value for anyone involved in change management. When Secretary of State for Health Andrew Lansley halted the work programmes under This report aims to capture the experience of the people who developed and implemented the Healthcare for London banner in 2010, this reflected the new coalition government’s the Healthcare for London vision.