Centralised and integrated NHS in balance

By the end of this week, the final stages of a transfer of services from various NHS sites across Glasgow to the South Glasgow Hospitals site is due to be complete. It has been described as the largest ever hospital migration in the UK.

The consolidation of services in a new £842m ‘super-hospital’ has met with some resistance, however.
The speed of transition has been criticised at a time when the NHS is struggling to cope with demand. Nursing leaders reported a local shortage of domestic staff and high vacancy levels in the nursing workforce.

Fifty-six professors and consultants, 23 specialty trainees in oncology and seven junior doctors at the Beatson West of Scotland Cancer Centre in Glasgow wrote an open letter to the health board in which they said the moves would put patients at risk.

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“There is no clear plan in place for who would stabilise deteriorating patients and transfer them off site to the safety of the acute hospital which lies the other side of the Clyde,” they wrote.

Health Secretary Shona Robison insisted the migration of services was in the interest of patients.
“The new hospital in Glasgow will transform care for thousands of patients. The transfer of services from the old hospitals is obviously a huge and complex operation which the board are overseeing. More staff and services are now transferring to the new site, and while that process is under way we have been in close contact with the board, who have assured us they are focusing on both managing the process and delivering the best possible care to patients,” she said.

The centralisation of specialist health services is not a new idea. Labour’s Malcolm Chisholm was Minister for Health when much of the plans for Glasgow were drawn up. 
“I feel quite an identification with the Glasgow stuff because the last thing I announced as health minister, three days before I got moved, was funding for the children’s hospital at the Southern, which is going to take place in the next week or two,” he says.

At that point, the SNP was firmly against the plans. The party said maternity services and 24-hour accident and emergency cover should be retained locally, and pledged an SNP government would force health boards to prove any centralisation proposal was a last resort and subject the plan to independent scrutiny. 

A 2005 report led by Professor David Kerr was criticised for advocating centralisation, with plans to close A&E departments in Monklands and Ayr resisted by the SNP.
Only a few weeks into the SNP Government in 2007, the then Health Minister, Nicola Sturgeon, said there “should be a clear policy presumption against centralisation”, and reversed the decision on Monklands and Ayr. However, the Scottish Government’s 2020 vision for healthcare in 2011 actually recognised many of Kerr’s recommendations.

“In the case of Glasgow, they basically have accepted the plans they opposed,” says Chisholm. “In fact, there’s a great deal of continuity in health policy. Someone at the weekend was criticising the SNP for actually taking on too much of our approach to health. I would not make this criticism!”

The Golden Jubilee Hospital in Clydebank typified the move to centralised specialist services when it was bought from the private sector in 2002 as a national waiting times centre, and the SNP Government has continued to back its role. Two weeks ago, it received an additional £1.5m to expand its specialist procedures by 1,550 extra operations per year.
The funding will enable the hospital to deliver an extra 200 foot and ankle procedures, 150 extra hip and knee joint replacements, and 1,200 more cataract operations each year in an attempt to ease pressure on territorial boards.

Robison said the move would reduce territorial boards’ use of private sector alternatives when trying to keep waiting times down.
“With an ageing population the NHS in Scotland is facing different challenges to a decade ago and we have seen a significant increase in the number of people needing cataract operations and joint procedures.
“Increasing the number of operations at the Golden Jubilee will help health boards to manage these increases in demand,” she said.

Jill Young, Chief Executive of the Golden Jubilee National Hospital, said: “Once again we are delighted even more patients will have access to our high quality services.
“This further expansion of the Golden Jubilee solidifies our position as the largest elective orthopaedic centre in Scotland, providing an expert role in both simple and complex conditions. We are also now one of the largest providers of ophthalmology in Scotland.
“Currently, we are carrying out over 25 per cent of all hip and knee replacements and at least 12 per cent of all cataract operations for NHS Scotland. This further expansion means even more patients will benefit from having their operations carried out by our orthopaedic and eye specialists within their treatment-time guarantee.”

For Chisholm, the Kerr review “put the brakes” on “over-zealous centralisation” of services in the early years of the Scottish Parliament. “I thought they came up with a balanced approach, neither too in favour of centralisation nor rejecting it where it was clinically desirable. I thought the Kerr report came to a good middle position. I think it reined it in a bit,” he says.

According to Chisholm, the Kerr review’s central recommendation was “keep it local wherever it’s possible but centralise it where it’s clinically beneficial. It’s as simple as that, really.”

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Continue reading for how Kerr fed into current strategies, and how health boards are seeking to redress the balance