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Future of small and specialist medical services in Britain
Grant-giving bodies also have a role in catalysing behaviour change. They could demand that recipient institutions have audit procedures in place; that grant proposals include details of the contribution of various parties to carrying out the research; and that the principal investigator outlines how he or she will foster the academic development of junior
Future of small and In the
lately reorganised
British National Health
costs.
Each time the NHS goes through one of its periodic convulsions, seeking improvement by dint of managerial change, small but critical components of the service get forgotten. Most of these specialist units are highly technical, and full understanding of the benefits accruing from them may reside in the minds of a very few highly specialised individuals. Communication between such specialists and managers has never been easy. Managers are largely preoccupied with meeting 90% of the needs of 90% of their population; innovators all too frequently lack promotional skills and protests are easily dismissed as clinical shroud waving. There is a role here for directors of public health in identifying the nature and level of need in their local population and advising managers accordingly. There is an added difficulty in that general practitioners are increasingly expected to take a broader perspective as they get involved in purchasing care for their patients. Their capacity to think beyond the individual for whom they are buying that care, and to invest in shared services with benefit to a collective of patients, remains to be developed. And the financial incentives do not work in this direction. Historically small services treating low-incidence conditions have developed in various ways. Clinicians often reached agreements to refer particular groups of
mutually designated units, an early example the care of patients with chorion epithelioma. being 316
open.
The Lancet
specialist medical services in Britain
Service (NHS) there is anxiety about the future of small and specialist services. We should not be surprised that these concerns have surfaced in medical rather than managerial journals.1 They are an uncomfortable reminder that the NHS differs from services such as public transport in which the downside is inconvenience rather than loss of life. Many NHS management systems are ostensibly directed towards improving equity and access to services. But if you are the parent of a child born with a rare congenital metabolic defect it will not feel equitable to discover that skill and experience in the diagnosis and treatment of this condition has succumbed to the law of the market. The service is no longer viable, you are told; insufficient patients "flowed" to the specialist unit to cover the fixed and running
cases to
members included in the research proposal. Grant reports should include a section for progress in these areas, including justification for the inclusion of authors of papers emerging from the work. It is high time these insidious practices were brought into the
For
biochemical assay services there was an agreement in principle that no region would be self-sufficient. For technically difficult tests-eg, for steroid hormones, cholinesterase, or trace metalstwo laboratories across Britain would take responsibility for development and quality control, and build up experience by maximising throughput. On a knock-for-knock basis this strategy led to each health service region containing specialist laboratories for two or three tests and serving a national (and even international) catchment. Other examples include the soft tissue pathology service and the purine laboratory service. The Department of Health itself recognised the existence of supraregional services, and has controlled their development and administered the resources for them under a system that still continues. Indeed, it is a measure of the prevailing confusion around the smaller specialist services that the unfettered force of the market has not as yet been let loose on the designated supraregional specialties. Before there are any spectacular and highly political crashes of well-known supraregional units, and before there are unsung disappearances of small specialised laboratories, there is just about time for the issue to be addressed. First we need a fact-finding exercise to reveal the dimensions of the situation in terms of the clinical conditions concerned, services available, activity levels, source of referrals, and expenditure. Various ideas have been put forwardl that could ensure proper resourcing without breaching the principle of the NHS market. One possibility is that each district could learn the hard way, and at the expense of patients, by examining these services individually and estimating its own population’s needs. However, at a time when purchasers are still learning their craft and concentrating on the larger services it would make more sense if a portfolio were produced centrally to depict the location of specialist clinical services, the likely estimate of demand arising from a certain population, and the quality standards on which a purchaser should insist. And ideally the Department of Health itself would address the question of resources for these small specialist services. The Lancet 1
Donaldson LJ. Maintaining excellence: the preservation and development of specialised services. BMJ 1992; 305: 1280-84.
Future of small and In the
lately reorganised
British National Health
costs.
Each time the NHS goes through one of its periodic convulsions, seeking improvement by dint of managerial change, small but critical components of the service get forgotten. Most of these specialist units are highly technical, and full understanding of the benefits accruing from them may reside in the minds of a very few highly specialised individuals. Communication between such specialists and managers has never been easy. Managers are largely preoccupied with meeting 90% of the needs of 90% of their population; innovators all too frequently lack promotional skills and protests are easily dismissed as clinical shroud waving. There is a role here for directors of public health in identifying the nature and level of need in their local population and advising managers accordingly. There is an added difficulty in that general practitioners are increasingly expected to take a broader perspective as they get involved in purchasing care for their patients. Their capacity to think beyond the individual for whom they are buying that care, and to invest in shared services with benefit to a collective of patients, remains to be developed. And the financial incentives do not work in this direction. Historically small services treating low-incidence conditions have developed in various ways. Clinicians often reached agreements to refer particular groups of
mutually designated units, an early example the care of patients with chorion epithelioma. being 316
open.
The Lancet
specialist medical services in Britain
Service (NHS) there is anxiety about the future of small and specialist services. We should not be surprised that these concerns have surfaced in medical rather than managerial journals.1 They are an uncomfortable reminder that the NHS differs from services such as public transport in which the downside is inconvenience rather than loss of life. Many NHS management systems are ostensibly directed towards improving equity and access to services. But if you are the parent of a child born with a rare congenital metabolic defect it will not feel equitable to discover that skill and experience in the diagnosis and treatment of this condition has succumbed to the law of the market. The service is no longer viable, you are told; insufficient patients "flowed" to the specialist unit to cover the fixed and running
cases to
members included in the research proposal. Grant reports should include a section for progress in these areas, including justification for the inclusion of authors of papers emerging from the work. It is high time these insidious practices were brought into the
For
biochemical assay services there was an agreement in principle that no region would be self-sufficient. For technically difficult tests-eg, for steroid hormones, cholinesterase, or trace metalstwo laboratories across Britain would take responsibility for development and quality control, and build up experience by maximising throughput. On a knock-for-knock basis this strategy led to each health service region containing specialist laboratories for two or three tests and serving a national (and even international) catchment. Other examples include the soft tissue pathology service and the purine laboratory service. The Department of Health itself recognised the existence of supraregional services, and has controlled their development and administered the resources for them under a system that still continues. Indeed, it is a measure of the prevailing confusion around the smaller specialist services that the unfettered force of the market has not as yet been let loose on the designated supraregional specialties. Before there are any spectacular and highly political crashes of well-known supraregional units, and before there are unsung disappearances of small specialised laboratories, there is just about time for the issue to be addressed. First we need a fact-finding exercise to reveal the dimensions of the situation in terms of the clinical conditions concerned, services available, activity levels, source of referrals, and expenditure. Various ideas have been put forwardl that could ensure proper resourcing without breaching the principle of the NHS market. One possibility is that each district could learn the hard way, and at the expense of patients, by examining these services individually and estimating its own population’s needs. However, at a time when purchasers are still learning their craft and concentrating on the larger services it would make more sense if a portfolio were produced centrally to depict the location of specialist clinical services, the likely estimate of demand arising from a certain population, and the quality standards on which a purchaser should insist. And ideally the Department of Health itself would address the question of resources for these small specialist services. The Lancet 1
Donaldson LJ. Maintaining excellence: the preservation and development of specialised services. BMJ 1992; 305: 1280-84.