STARTING FROM SCRATCH: THE LONDON NHS PLAN SUGGESTS GORDON BROWN MEANS BUSINESS ON HEALTHCARE REFORM. ITS ARCHITECT, SIR ARA DARZI, TELLS JOHN CARVEL ABOUT HOSPITAL CLOSURES, POLITICS AND THE NEED FOR MAJOR CHANGE

The Guardian – United Kingdom
Published: Jul 11, 2007

At the cutting edge

Ari Darzi will continue practising as a clinician two days a week
while also working as a junior health minister Photograph: Matt Writtle

T he political significance of Gordon Brown’s decision to appoint an
Armenian-born pioneer of keyhole surgery as the health minister for
England becomes apparent today. Sir Ara Darzi, 47, is professor of
surgery at Imperial College London. He has a glittering international
reputation for making clinical advances in minimally invasive and
robot-assisted surgery.

He brings to the government the credibility of a practising
consultant who will continue to spend two days a week in the operating
theatre. And last week he was put in charge of a review of the NHS to
determine the next stages of reform after the government has achieved
the target of reducing the maximum wait for hospital treatment to 18
weeks by the end of next year.

Until today, it was possible to interpret Brown’s choice of Darzi as
a calming gesture towards the medical profession. Instead of having
politicians or managers telling the health service what to do, he
was putting one of their own in charge of mapping out the future.

But Darzi’s 10-year plan for reorganising the NHS in London is anything
but calming. However brilliant the conception, it is a recipe for
turbulence.

The document – due to be published by the London strategic health
authority today – proposes a massive shift of work from hospitals
into polyclinics and urgent care centres that would cater for most
people’s medical needs closer to home.

The plan is revolutionary. It says: "The days of the district general
hospital seeking to provide all services to a high enough standard
are over." In Darzi’s view, it is not safe or economic to treat
patients with complex needs in a hospital where staff have too little
experience of the condition. Those patients should go to specialist
hospitals. London already has six, including the internationally
renowned Great Ormond Street hospital for children and the Royal
Marsden for cancer patients.

Darzi thinks that the capital needs up to 12 specialist hospitals,
between eight and 16 major acute hospitals, and a handful of "academic
health science centres" created by integrating top hospitals with
universities’ biomedical research centres. That implies that many
of London’s big general hospitals would lose their maternity and
paediatric departments, and that they would no longer carry out major
surgery at night. Ambulances, blue lights flashing, would take the
most seriously ill patients to other hospitals with more advanced
facilities.

The rationale behind the proposals may be familiar to anyone who heard
Patricia Hewitt, the former health secretary, when she called for 5%
of hospital work to transfer into the community and the most complex
surgery to be carried out in regional specialist centres. But the
scale of Darzi’s reorganisation is vastly more ambitious. He has been
working on the London strategy since September, and it is probably
coincidental that the document was scheduled for publication so soon
after Brown entered No 10.

But the prime minister knew about the radicalism of Darzi’s vision
before giving him ministerial office. On the day before Brown was
formally anointed party leader last month, he sat in on one of Darzi’s
public consultation events. By backing Darzi, Brown showed he was
more interested in changing the NHS than making cosmetic adjustments
to defuse tensions in time for the general election.

Of course, Darzi is only the junior minister. Alan Johnson, the
health secretary, has the seat in cabinet. Johnson is the captain with
responsibility for sailing the NHS ship safely into port in time for
the general election. But Darzi has the keys to the map room to chart
the next voyage.

Talking to Society Guardian after operating on a patient at St
Mary’s hospital in Paddington, west London, on Friday, Darzi says:
"The review of London’s healthcare has dominated my life for the past
eight months. It was possibly the most challenging work anyone could
do while still contributing as a clinician. I have worked in London
for many years, but was never before exposed to the bigger picture."

He found huge contrasts. Top teaching hospitals and university
biomedical departments are at the cutting edge of global medical
advance, but across the capital, in pockets of social deprivation,
people are dying unnecessarily, due in part to poor healthcare.

Westminster and Canning Town are separated by only eight stops on
the Jubilee line as it runs from the centre of London to the East
End, yet life expectancy in Canning Town is seven years less than
in Westminster.

Darzi found there were fewer GPs per head in areas where the health
needs were greatest. Doctors in large acute hospitals in London saw 24%
fewer patients than their counterparts elsewhere in Britain. About 22%
of Londoners are dissatisfied with the way the NHS is run, compared
with 18% nationally. The review concluded: "Continuing with the old
ways of doing things will not only be ineffective, it is also likely
to be unaffordable."

Darzi says he wanted his review to be different from anything that had
been tried before. Instead of starting with the hospital estate and
thinking how it could be better used, he began by analysing patients’
needs from cradle to the grave.

"This is not the Darzi report," he insists. "A troop of 60 clinicians
went through this with me. They were not the great and the good,
but people working on the shop floor. I challenged them with three
questions. What are the clinical pathways that you provide for your
patients now? What are the best clinical pathways that you would wish
to deliver for your patients? And how do we make that happen?"

This amounted to working out how the NHS in London should look if it
were being built from scratch.

The clinicians set to work marrying polling research about what
patients said they wanted with medical research about the most
effective way of delivering care. One of their mottos was: "Localise
where possible, centralise where necessary." Other principles included
maximum cooperation between health and social services to stop people
falling through the gaps, more emphasis on health promotion, and a
strong focus on health inequalities and ethnic diversity.

The result is a blueprint for a radically different NHS. Darzi believes
50% of the work done in district general hospitals can be devolved to
local level. That would include more care being delivered in people’s
homes – particularly during maternity and towards the end of life.

A network of 150 polyclinics would "provide a new kind of
community-based care at a level that falls between the current
general practice and the traditional district general hospital". Minor
emergencies would be treated at urgent care centres dotted around the
capital, and the ambulance service would be upgraded to take the most
seriously ill directly to major acute hospitals or trauma centres.

This is a more comprehensive version of changes that have sparked
protests around the country – often supported by Labour ministers
who recognise constituents’ attachment to having the full range of
services available at the local hospital.

But Darzi believes he can carry Londoners with him by explaining
the clinical reasons for reform. For example, the status quo is
unacceptable for stroke patients who are not getting the right care. He
wants them to be treated in seven "hyper-acute" stroke centres.

"I don’t think there will be any closures of hospitals," Darzi
says. "Our analytic work suggests that what we need is to redefine
the function of buildings over the next decade." The London NHS
estate covers more than 1.5 sq miles – making it larger than the
City of London, on which much of the capital’s wealth depends. Many
hospitals are on prime sites, some of which could be released for
affordable housing. "I am not suggesting we sell the family silver,"
Darzi insists, "but creative enterprise can raise a lot on the back
of these assets."

He does not think private finance initiative (PFI) contracts locking
the NHS into 30 years of repayments on old-style hospitals are a
problem. If a district general hospital converts to become a local or
specialist hospital, the PFI costs will, he maintains, stay the same.

Darzi has no map showing which hospitals will become the hubs of
advanced medicine and which will lose some functions and status. That
will not emerge until after the strategic health authority has
completed a formal public consultation on the plan and primary care
trusts translate it into a 10-year programme.

He knows this will not be plain sailing. "The public say hospital
is not the only answer, but they also say don’t tinker with what we
have got until there is something better in place." The plan includes
investment in up to a dozen new polyclinics to whet the public’s
appetite for change.

Darzi’s family were among the survivors of the Armenian genocide in
the early 20th century. He was brought up in Iraq, where, like other
Christian Armenians, he attended a Jewish community school. At 17,
he went to university in Dublin and got his medical degree at Trinity
College. Darzi has an Irish wife and a slight Irish accent. "Take me
out for a drink and you will see I’m a Paddy," he says. He completed
his medical training at Central Middlesex and St Mary’s hospitals in
London, where he has combined hands-on surgery with a professorship
at Imperial College.

Now, as he starts work on the national NHS review, he asks patients
and voters to avoid jumping to the conclusion that his prescription
for London will be the right medicine for the whole country. His style
of working will be the same. He intends to "engage with the clinical
community and the public". And he will draw on the best international
research about quality and safety. But he maintains that London is
unique. The national review "could use the same processes, but the
recommendations would be very different".

Does this mean that Brown is committed to further heavy-duty NHS
reform?

Darzi does not say yes or no, but he accepts that the prime minister
has signed up to a process of clinical engagement. "Reform is here
to stay," he says. "Forget about the politics. I don’t have any
political experience.

But, as a clinician, I can tell you this: it is refreshing to take
a deep breath and look where we are on this journey.

"There is a reason why, as a clinician, I was asked to do this
[national] piece of work. We put the money in. We have done the
reforms. But we have not described to staff and users where this
journey is going.

"In London, I have been through this journey for the last eight
months. I can reassure you, I have carried everyone with me. The report
is based on what clinicians are telling me, what the public are telling
me, and what the clinical evidence suggests. Change causes turbulence
in all aspects of life, in all professions. The only difference here
is that we are talking about the quality of patient care."