Healthcare for London (3)

hospital de St. Mary, paddington, londres

Regressado ao Saudesa após 15 dias de férias sem Internet, dois temas despertaram a minha atenção, havendo pontos de contacto nas razões pelas quais são para mim apelativos. São eles a divulgação “oficial” do Relatório sobre a Sustentabilidade do SNS link (sobre o qual hoje não vou pronunciar-me) e o plano "Healthcare for London", coordenado pelo Prof. Ara Darzi. link link

Ambos são trabalhos extensos e fundamentados, dos quais, obviamente, se pode discordar. Mas só fica bem fazê-lo numa base também documentada e fundamentada e não sobre considerações derivadas de opções individuais prévias ou da afectividade de cada um, porque estas considerações, quer pela prontidão com que são aduzidas, quer pelo próprio conteúdo, sugerem, muitas vezes, que foi dispensada a ponderação – quando não também a leitura – do texto objecto do comentário. No entanto, não é do conteúdo, ou das soluções propostas, que vou ocupar-me. Limitar-me-ei a aspectos meramente formais, embora também, naturalmente, importantes e condicionadores do sucesso da acção quando as propostas chegam à fase da implementação. O que pretendo realçar é a forma de decidir, preparar e facilitar a mudança para que ela possa passar das páginas das propostas ou das decisões para o mundo do real, produzindo o sucesso esperado que a justifica e para que sejam minimizados, até onde possível, os percalços em curso de execução e os efeitos adversos que tenham de ser suportados.
Devo, antes que avance, fazer a minha declaração de interesses: de longa data, vejo com expectativas elevadas a literatura produzida pelos gabinetes de Sua Majestade na abordagem dos problemas, quer pela sua objectividade quer pelo poder de convicção ou pela consistência da argumentação apresentada.
Aqui me encontro, mais uma vez, com o comentário do É-Pá: “A leitura deste plano "Healthcare for London" evidencia, em relação a nós, duas posturas culturais, diametralmente, opostas”. link
Onde está a oposição? Para mim, sobretudo na forma de condução dos processos. Exemplifiquemos.

Encerrámos maternidades e serviços de urgência (ou que tais) – medidas que até se afiguram correctas! – com as reacções que ainda temos bem presentes. Alguém se lembra de qualquer iniciativa, minimamente consistente, levada a cabo para explicar as razões que impunham tais medidas às populações supostamente atingidas, ou mesmo só às entidades que as devem representar? Foi prévia e adequadamente divulgada a necessidade da mudança, ou seja, os riscos a que a situação anterior estava a expor essas populações (sobretudo as sequelas, para a vida inteira, de partos realizados sem as condições de segurança possível) e os custos que, em alternativa, teria a sua superação? Não se tendo feito, não se tendo mostrado como essas medidas se integram numa política global de saúde dirigida à melhor satisfação das necessidades de saúde da população (concretamente, da população atingida), a esta ficou a alternativa de as considerar mais uma “espoliação” de direitos adquiridos, mais um episódio de descriminação negativa do interior (tanto mais que os grandes centros urbanos não foram atingidos de forma visível), e tudo derivado do único propósito de economizar nos locais onde já se gasta menos, em saúde como no resto, agravando ainda mais o deficit de equidade do SNS.

E no RU? Com base apenas no Sumário Executivo do plano "Healthcare for London" (donde extraio as citações seguintes) vejamos, em contraponto, quanto cuidado é posto na abordagem das temáticas e na busca de consistência para lhes conferir aceitabilidade.

a) – Promover a equidade e a satisfação da população, enfrentar os desafios:
- Equity of care is a founding principle of the NHS, but healthcare in London is not equitable, either in terms of mental and physical health outcomes, or in terms of the funding and quality of services offered (Ponto 3). …One of the main themes of this report is the importance of reducing health inequalities by giving everyone access to the best possible care. … So I will be expecting both local and strategic implementation to make systematic use of health inequalities impact assessments to ensure improvements are helping those who are currently the least well-served by the NHS. (Ponto 31);
- … Twenty-seven per cent of Londoners are dissatisfied with the running of the NHS compared with eighteen per cent nationally. Londoners are also less satisfied than people nationally with their GP services (Ponto 3);
- This report … also reflects a major exercise to hear what Londoners say they want from their healthcare system. It sets out a compelling ten-year vision for healthcare in London. (Ponto 2);
- Verificam-se …notably high rates of HIV, substance misuse, mental health problems, and high rates of childhood obesity. …O NHS must to be able to meet the needs of our wonderfully diverse and highly mobile population. The NHS must be accessible to all. (Ponto 3);
- The hospital is not always the answer. As set out in the White Paper, Our health, our care, our say, most people are best cared for by community services. But 97 per cent of London outpatient appointments still take place in hospital. And, dissatisfied with the availability of GP services out of working hours, Londoners are instead using A&E departments for urgent care. (Ponto3);
- We need to provide more specialised care. …the most seriously ill need more specialised care. In order to ensure sufficient volumes of work ... specialised services need to be centralised in fewer hospitals catering for large populations. (Ponto 3);
- We are not using our workforce and buildings effectively. …Productivity levels in London are lower than elsewhere in England. … The NHS estate is a huge and hugely underutilised resource. (Ponto 3);
- We need to make the best use of taxpayers’ money. …The NHS in London would be failing in its duty to its population if it did not make best use of the money it has. Money wasted through inefficiency in one aspect of healthcare is money that could have been used to save lives elsewhere. … The only way for future healthcare provision to be sustainable is changing to ensure care is provided in the most cost-effective way. (Ponto 3);
- …The UK as a whole risks lagging behind its international competitors. London needs to explore the model of Academic Health Science Centres being followed by other large cities if it wants to be at the cutting-edge of research and clinical excellence. (Ponto 3);
- It is clear that demand for NHS services is only going to grow. Our detailed modelling makes it clear that continuing with the old ways of doing things will not only be ineffective, it is also likely to be unaffordable. Any proposals for change need to show that they take into account our best predictions of what the future will bring. (Ponto 9);
- Our detailed feasibility modelling suggests that our proposed new model would, in the most likely growth scenario for demand in health services, save the NHS £1.5 billion each year. So these changes are necessary not just to improve services, but also to make future activity affordable. An NHS with a strong emphasis on prevention and early intervention saves lives and saves money.(Ponto 26);

b) Enunciar os princípios para a mudança (Ponto 11)
• Services focused on individual needs and choices. … Patients should feel in control of their care and be able to make informed choices;
• Localise where possible, centralise where necessary. Routine healthcare should take place as close to home as possible. More complex care should be centralised …;
•Truly integrated care and partnership working, maximising the contribution of the entire workforce. Better communication and co-operation is needed. …Care should be multidisciplinary, bringing together the valuable contributions of practitioners from different disciplines. …;
• Prevention is better than cure. Health improvement, including proactive care for people with long-term conditions, should be embedded in everything the NHS does. Close working with local authority partners is needed to help people stay mentally and physically healthy;
• A focus on health inequalities and diversity. … The most deprived areas of London … need better access to high quality healthcare. … Improvements also need to take into account London’s rich ethnic and cultural diversity. We are advocating that patients have more information to make choices about their care and this should be accessible to all;

c) – Criar condições para o sucesso (Ponto 29)
… This report identifies the main drivers for change and improvement that will ensure the vision in this Framework becomes a reality, and demonstrates the part that everyone in the NHS can play.
• Commissioning. Commissioning is potentially a very powerful lever for driving change. We need the right commissioning skills and structure, and we need to commission in partnership with others;
• Partnerships to improve health. The NHS has often made the mistake of thinking it can change healthcare outcomes on its own. It cannot. The NHS must work with its partners – the London boroughs, the Greater London Authority and the Mayor’s Office, the voluntary and private sectors, and the higher education sector – to implement this Framework;
• Public support. For change to succeed both the public and politicians need to believe that it is in the public’s interest. The clinical case for change needs to be clearly made. And there needs to be up-front investment to help put new services in place quickly and win public support for change;
• Clinical leadership. The whole approach of this review has been to develop clinical support for our proposals. But it is easy to support principles for London, harder to support change in the hospital or locale where you work. Many clinicians understandably fear that change will affect their job satisfaction, their autonomy, their clinical reputation. To confront and assuage these fears, NHS London needs to identify clinical champions to make the case for change;.
• Training and the workforce. Clinical leadership is important but so too is the development of the workforce more broadly. New models will call for new roles and new skills. NHS London needs a single workforce strategy to help align recruitment and training with changing needs;
• Patient choice and information. The choices that patients make about their healthcare will increasingly drive change and improvement. The better the information, the more those choices can drive improvement. Information for choice needs to be developed in priority areas such as GP and maternity services;
• Funding flows. Commissioning can only drive change if it has a direct impact on the income of healthcare providers. Funding flows need to be used to incentivise the best practice contained in this report. At its simplest, this means commissioners defining the best, safest practice for a patient pathway and then ensuring that this and only this is the practice they pay for;
• Better use of our estates. The NHS in London has a huge and under-utilised estate. We need a comprehensive estates strategy to support this Framework, including exploring how surplus or underused estate can be used to finance new developments.
Não valerá a pena acrescentar mais nada. As diferenças saltam à vista.
AIDENÓS