Category Archives: NHS Hospitals

I have often wondered, during all the discussion of whether one’s local hospital should be shut down, whether hospitals are safe places for patients to be in. Let me rephrase that. Are they safer places to be in, rather than your own home?

I tend to think, surely, that clinicians can’t think hospitals are particularly safe places to be in, otherwise they wouldn’t be in such a rush to have them ‘flow’ in and out? But there are of course economic considerations, for example the cost of a hospital bed being more than the cost of a bed at the Ritz, and so on.

The Royal Colleges of Physicians have warned on numerous occasions about the service being understaffed and overstretched, and the Royal College of Nursing and others have for a long time, famously, been campaigning for safe staffing.

Patient safety supposedly is King, but the problems appear not to go away. The issues with patient safety continue to linger like a bad smell. Take, for example, the Mid Staffs scandal and the current issues with the NMC and maternity care deaths.

In recent years, the focus seems to have been on structures, processes and operations, rather than people and needs. Whilst the slogan ‘person-centred integrated care’ is everywhere, it continues to be the case, perhaps, that people have to be built round services rather than services fitting round people.

For many outpatients, a trip to outpatient’s can be an unpleasant experience, especially if you’re travelling a long distance by car and then have to negotiate an astronomic car-parking fee at the end of it. For patients who are literally bed-bound, and who can otherwise travel only with a carer and a wheelchair, a trip to hospital can be a monumental task.

Hospitals can be the very worst places for certain groups of patients, for example patients who are frail, living with dementia and experiencing delirium. A sudden change of environment from home to hospital can be catastrophic for the delirium, and so can a plethora of other issues in hospital (such as bed rails, lack of communication, inappropriate sedation, inappropriate extensive de-prescribing, etc.)

Whilst hashtag campaigns can be somewhat hyperbolic, it is true that the #endPJParalysis campaign has drawn attention to the issue of patients languishing in beds for weeks such that when they are finally discharged they can no longer walk and have lost their ability to perform certain activities of daily living.

And the medical issues resulting from hospitals, including hospital-acquired infection, pressure sores, DVTs, are well known.

An issue with integration and making a case for change is that, particularly following the introduction of the ubiquitously-despised Health and Social Care Act (2012) from Andrew Lansley, the natural reaction has been to assume that everything is essentially a cost-cutting exercise on the road to privatisation.

But the case of artificially dividing health and social care is no longer tenable. Ahead of talk on processes and structures, such as pooled budgets and organisational structure, there is a basic issue that people for example with long term conditions such as frailty and dementia can have substantial care needs, such as personal care or washing and dressing.

It has long been claimed that mortality is unaffected in palliative care, but anecdotal evidence appears to be that certain healthier patients, despite living with life-limiting terminal conditions, can live longer if in better health.

It could be that one’s own home is a safer place to be?

With initiatives such as ‘NHS Ageing Well’, if we are to take seriously living independently and reablement, we do need to make sure physical health, social health and mental health are on the same footing. This has for ages has been known as ‘making parity a reality’.

In a report from the King’s Fund on #socialcareoptions this morning, it’s been argued that we’ve reached a fork in the road between the universal NHS and means-tested social care system.

I believe strongly that the divide between health and social care is utterly unproductive, and that we cannot have a system which unfairly discriminates against service users to their financial detriment according to what a condition is.

It could be that there is a genuine issue with safety in hospitals (a “push” factor). And that people’s quality of life is genuinely enhanced with independence, provided that this does not lead to isolation (a “pull factor”).

But I think, personally, the idea of hospitals being the “ultimate institution” is long dead. I’ve never met a single patient who says he’s really ‘enjoyed’ being in hospital, and further might exacerbate the sense of ‘otherness’ people with certain conditions might feel.

The NHS is a movement, rather than, merely, a collection of buildings (like hospices are a movement). With the growth of ‘hospitals at home’, there is now a tendency for promoting health, not just fixing illness, to need to take place at the right place, right time, and right way.

 

 

@dr_shibley

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Just a few weeks ago, those who like to keep a keen eye on the local press may have seen a very forthright article in the Southport Visiter which in no uncertain terms declared the future of Southport Hospital and its A&E “safe” and “not under threat”.  It followed fears for the hospital after criticism of surgical standards and safety and also the privatisation of its community and urgent care services, which went to Virgin Care in a contract worth £65m.

 The biggest question mark hanging over it though was the proposal to downgrade the A&E, contained in the Conservative Government’s Sustainability and Transformation Plan project for the NHS, known as the STP.
The town’s new Conservative MP, Damien Moore, featured heavily in the Visiter article and he firmly dismissed concerns about the hospital’s future stating “the suggestion that Southport Hospital needs ‘saving’ is nonsensical and misleading”.  Towards the end of his considerable contribution even the keen-eyed might have missed that he did not completely shut the door on the possibility of “considerable change” but as he soothed the readership by claiming that, if so, it would be a decision for “experienced medical professionals – not bureaucrats or politicians – and on the basis of patient safety”, it might not have set alarms bells ringing. It certainly should have. In any event, they might possibly have been drowned out by all the thundering reassurance on offer, given it was then immediately stated in the piece that “the future of the hospital has never been more clear”. With support from Health Minister Phillip Dunne and, apparently, Trust Chairman Richard Fraser, it appeared Southport’s new MP was basically trying out his good beat cop routine for the first time, best paraphrased as, “All’s fine, nothing to see here, move along now folks please.” It was a bold and confident move that deserved a “Bravo” for its bravura, perhaps it even earned him a Charlie, Lima, Alpha, Papa, back in the control room of Conservative HQ.
Contrast this then with the scenes at the hospital for this week’s visit by Secretary of State for Health, Jeremy Hunt.
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Over 100 protestors, the vast majority Mr. Moore’s own constituents, had gathered at the main entrance to voice their concern for the hospital and their disapproval of Mr. Hunt and Conservative cuts. Organised by Southport Labour and Liz Savage, the town’s Parliamentary Candidate in 2015 and ’17, the protest also involved the GMB, Royal College of Nursing, hospital staff and Sefton Central MP, Bill Esterson.
 Attending the hospital as part of the Hunt entourage, the previously bold Mr Moore decided to avoid them all by taking a side entrance. It wasn’t the only apparent change in attitude by him.  When interviewed on site by BBC North West Tonight’s Health Correspondent, Gill Dummigan, he rightly pointed to the hospital’s recent improvement in care standards. He also told her that the future of the hospital was secure. When the doughty Dummigan specifically asked about the future of the A&E, however, his response was described by the reporter as “less certain”. Indeed, it seemed the only thing Mr Moore was more certain of was his determination to give the hospital trust the old “hospital pass” on this one.
At present, there is a local review of service provision in process. This review comes after plans to downgrade the A&E were included in the local version of the STP, the vehicle by which Mrs May’s Government are looking to make over £900m in cuts in Cheshire and Merseyside. Consequently, the review report is also a big part of the uncertainty hanging over the hospital’s future capability. When asked if he was confident that there would be an A&E at Southport Hospital in a couple of years time, the previously confident Mr Moore didn’t seem so, well, confident. He replied:  “What I’m waiting for is to see what that report says and to actually trust medical professionals to make the decisions based on Southport people”. The health correspondent then asked the MP “So you can’t be certain?”  His repetitive response was anything but:   “I’m waiting on to see what the report says but I’m positive about the work that’s happening in Southport hospital at the moment.”
 We are all sure there is a lot of positive work happening in Southport Hospital every day Mr. Moore but the question was, is the future of the A&E safe?

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 The problem for Southport Hospital, its NHS trust, and the people of Southport is that instead of actually being a good beat cop, Mr. Moore appears to be playing political “cups and ball” with the A&E issue. “Cups” is the age old game where you have to guess which of the three cups the ball is under. It’s a favourite back alley hustle the world over and a classic of the art of misdirection.  In this case, the “ball” is the decision on the A&E and the cups are the supposed decision makers. Is it a clinical decision? Is it an administrative decision? Is it a joint decision after public consultation?
As he referred to specifically in the Visiter and by implication in his BBC interview, Mr Moore wants you to believe that the ball currently is with a clinical senate of the hospital trust and its “experienced medical professionals” but it is misdirection. The reality is that whichever “cup” it is actually under, what’s important to understand is that it’s the Conservative Government placing the ball and moving the cups.
During his visit to the hospital, we understand that Jeremy Hunt found himself unexpectedly confronted by medical staff who essentially gatecrashed the talk he was there for. A junior doctor challenged him over his previous claims regarding the “Weekend Effect” on mortality rates so recently and publicly derided by Professor Stephen Hawking. Mr Hunt showed he’s no slouch at misdirection himself by appearing to suggest to those assembled that HE was the one defending the NHS from Prof. Hawking! We certainly did not see that one coming. He also said that due to the conflicting evidence on the issue he’d been advised to choose the side he did. It seems an oddly unscientific basis for such controversial claims, for his proposed changes to hospital working practices, and for subsequently getting into an argument with the world’s most famous scientist and was one which led to claims of cherry-picking from the audience.
hunt___moore_resize_7.jpgIn addition to all this, we believe that the hospital chaplain no less asked him for reassurances about A&E. We suspect Mr Hunt did not earn himself any grace by refusing to give any. A senior consultant meanwhile asked if the Secretary of State could reassure them that the STP would address the yawning gaps in recruitment, once more the ball was placed under a cup when Mr Hunt responded that this would be a matter for the local STP.
He did tell the meeting that he was fully committed to the NHS but then also said that as a Conservative he was opposed to publicly owned services. This as he stood talking to public sector workers, on public sector land, in a public sector hospital. It does not bode well but perhaps it’s not so surprising from the man who literally co-wrote the book on how to dismantle the NHS and replace it with a US-style private medical insurance system. The man the Conservatives have put in charge of the NHS.
One can only assume that at this point in proceedings local MP Mr. Moore preferred to smile and shuffle his feet rather than the cups, it would prove much harder to fool the trained eye of the hospital doctors and staff after all. hunt___moore_resize_6.jpg

Birthplace of the NHS

There is a significant and rather sad irony in all of this, as Southport actually has a strong claim to being the birthplace of the NHS. Back in 1934 at the Garrick Theatre on Lord Street, it’s now the town’s bingo hall, the Labour Party held its annual conference. It was at that conference that the creation of a national health service was first adopted as party policy.  It took 14 years, a second world war and the resulting Labour Government for it to come into being. In the meantime, it has become the cornerstone of our welfare system, a point of national pride and an object of international envy.
Since 2010, however, it has also been under assault after austerity measures were introduced by the Coalition government of the Conservatives and Liberal Democrats.
The 2012 Health and Social Care Act they brought in also allowed the once creeping now sweeping privatisation that is currently undermining it. It’s what enabled Virgin Care to take over those services from Southport Hospital this summer.  The Conservative’s ramping up of the austerity programme has further hamstrung NHS funding; their 1% pay cap is further demoralising its staff.
Massively dependent on foreign staff, the huge uncertainty over Brexit has seen an equally massive 96% reduction in EU nationals applying to work in it. Meanwhile, the Tory backed Naylor Report means NHS trusts are being coerced into selling off the very land they stand on.
Against this background, make no mistake, the future of Southport Hospital and its A&E is not certain; it is not safe; nor confident; nor bold.  
Most importantly, despite what Mr. Moore wants you to believe, the current decisions over service provision and the future of our town’s A&E are not at their root actually a clinical matter, it is instead essentially a matter of choice made by a Conservative government hell-bent on further cuts, one that clinicians and administrators are struggling to do their best with. If that ultimately means downgrading our A&E, Southport’s residents will also struggle. In such distressing circumstances, the people of Southport will not forget how their local MP and his party played a game with them and their hospital’s future. That at least will be clear.
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First published on Southport Labour Party blog
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NHS hospitals in England are forecasting a £2.3 billion deficit by the end of the financial year. This is a big increase from £115m in 2013-14 and £822m in 2014-15. Hospitals are calling for debt relief and bailouts.

These deficits threaten plans to transform the NHS. Of the £2.14 billion devoted to implementing these plans in 2016-17, £1.8 billion is being spent on clearing deficits. This leaves just £340m to support the vision for integrated care and the promised “radical upgrade in prevention and public health”. And channelling more money to hospitals means less is available for community and mental health services. So dealing with these deficits is skewing NHS priorities now and into the future.

But what has caused the deficits and what can be done about them?

Grounds for complaint

Hospitals blame the deficits on things outside their control. They have two main grounds for complaint. First, they are not paid enough for the care they provide. Hospitals are paid according to how many and what type of patients they treat. When this payment system was introduced in 2003-4 the price per treatment was based on average costs reported by all hospitals. But since 2005-6 prices have been reduced by an annual “efficiency factor”. From 2011-12 to 2014-15, this was a particularly challenging 4%. Hospitals have been unable to meet this challenge in full each year. These shortfalls have contributed to the deficits.

In January 2015, hospitals rebelled, objecting to a proposed efficiency target of 3.8% for 2015-16. The target was subsequently dropped and, in a reversal of past policy, 2016-17 prices are to include a 1% “cost uplift”. But the deficit damage has already been done.

The second point is that hospitals are treating more patients because other parts of the system aren’t working effectively. For instance, more people are going to A&E because social care support has been cut back and because the new 111 telephone service advises more people to go to A&E than the old NHS Direct.

Similarly, emergency admissions to hospital have been rising by 2.4% a year since 2011-12 and by 3.7% between 2013-14 and 2014-15. If patients turn up needing emergency care, hospitals can’t simply turn them away. While hospitals get paid more, the more patients they treat, since 2010 they have received only 30% of the usual price for emergency patients. Hospitals complain this isn’t enough, and it has now been increased to 70%.

Patients are being ‘sucked into hospital’.
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Running up deficits

But there are counter-arguments that hospital deficits are partly of their own making. Hospitals are indeed treating more patients, but do they all need hospital treatment? While emergency activity has been increasing, elective activity has been increasing even faster, by 3.5% a year since 2011-12, and 5.1% between 2013-14 and 2014-15. The fastest growth has been for people coming to hospital for investigations and day-case treatment. Some of these people might have been treated elsewhere, but there have been long-standing concerns that patients would be “sucked into hospital” by hospitals wanting to increase their income.

This will only get them out of financial trouble, however, if the additional income generated covers the extra costs incurred. That is increasingly unlikely because prices are based on average costs minus the annual efficiency factor. This makes it more difficult to cover the costs of treating more patients.

To make matters worse, most hospitals have little understanding of how much it costs to treat their patients. The best information comes from patient-level costing systems but only 42% of hospitals are using these. If they don’t have accurate cost information, hospitals can’t tell whether treating more patients will relieve financial pressure. If costs are higher than income, treating ever more patients will make deficits worse.

What next?

The original attraction of the English hospital payment system was that it offered equal pay for equal work – hospitals are all paid the same price for a particular treatment. This principle remains sound, but the payment system needs refining, although the recent removal of the efficiency factor and price increases for emergency admissions should improve matters.

When the payment system was first introduced, it was also hoped that money saved by preventing hospital admissions could be invested in alternatives to hospital care. But there has been little success in preventing emergency admissions and even less in reducing elective admissions. The result has been that hospitals have been accounting for an increasing proportion of NHS expenditure over time. That trend won’t change while extra money is being used to bail out hospitals. And it won’t change until hospitals stop focusing solely on income growth. They have to start getting a better grip on their costs.The Conversation

Andrew Street, Professor, Centre for Health Economics, University of York

This article was originally published on The Conversation. Read the original article.

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Tells the story of those who work in one of the most unnoticed and unappreciated sectors of the British National Health Service. This short documentary offers a unique insight into the joint notions of life and death through the men whose job it is to deal with them on a daily basis.

Made in  Royal Bournemouth Hospital

Director: Dan Ridgeon, James Dougan & Max Cutting
Producer: Dan Ridgeon
DOP: Max Cutting
Editors: James Dougan & Max Cutting

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Why fill our hospitals with vending machines and Costa coffee shops when we are fighting a massive obesity epidemic?

Sally Norton is a NHS consultant, specialising in weight loss and upper gastrointestinal surgery, on a crusade to put herself out of work by promoting healthier behaviour.

At last, with health secretary Jeremy Hunt’s announcement of new measures being introduced to improve the standard of food in English hospitals, we may finally see better quality food in our hospitals.

These changes will see hospitals ranked according to the quality and choice of the food they serve. They will hopefully provide some sanity, and not before time, because I was beginning to think I was going mad.

We read every week, in The BMJ and other leading medical journals, of research detailing the perils of sugar and fizzy drinks. We frequently hear laments about the cost to the NHS of the epidemic of obesity and type 2 diabetes, which is threatening to engulf us. And yet, the NHS, which I understood to be an organisation that promotes and supports health (rather than just treating disease), is actually contributing to the problem.

As a weight loss surgeon, I find it frustrating and, frankly, embarrassing to spend time in clinic, explaining to my patients how sugary drinks and snacks are one of the biggest drivers of obesity, when I know that just outside in our hospital foyer are not one, but two Costa coffee shops, as well as vending machines stocked full of coke and chocolate.

Coffee with whipped cream

When I try to grab a quick coffee from Costa, an obedient employee always tries to tempt me into buying one of their huge, sugar-laden and calorific cakes to go with it . . . hard to resist after a stressful morning in theatre or a busy night on-call. If I did need a snack, I would be hard pushed to find much that you could describe as healthy—there is very little fresh, nutrient-rich food and next to nothing that doesn’t involve a load of refined carbs.

I no longer shake the hands of patients as they come in through the clinic door—more often than not, they are clutching their Costa take-outs, which they have been tempted into buying while waiting for their consultation.

I know I can’t be the only one who thinks that a hospital should be setting a good example for its patients, visitors . . . and its staff.

As we recently heard from Simon Stevens, NHS England’s chief executive, many of our NHS staff are hardly role models for our patients. And, from my own experience, I frequently hear the amazed reactions from patients when they see morbidly obese staff members providing advice on healthcare.

Of course, NHS staff are human too and subject to the usual lack of willpower that makes these sugar-laden temptations difficult to resist . . . although we do have the education to know that we should be trying to do better. However, the stressful environment in which we work, coupled with the unsociable hours, means that we need to have access at all times to good, nutritious food—not a vending machine promising us a sugary quick fix.

However, the old chestnut that it is all down to the individual, and that people should be able to control their cravings, just doesn’t wash. With two thirds of the English population classed as being overweight, we would be tarring a lot of people with the same “weak willed” brush. The problem is as much the food environment that we are constantly subjected to, as it is an individual issue.

The food we eat is now much more densely packed with fat and sugar than it used to be, so we are passively consuming far more calories than we may realise. The cheapness of the food, and the increasingly huge portions, available wherever we turn, mean that we are actively consuming far more too. In addition, more and more evidence is accruing that sugar is addictive, and that we are in a downward spiral of poor eating owing to the excess of highly processed carbs that make up the vast bulk of our diets.

The government seems unable to take a significant stand against the insidious pervasiveness of the food industry, but the NHS can and should make a stand. If we can’t be the leading light in promoting healthy eating, then who can? Shame on us, for allowing most of our hospitals to play willing hosts to the fast food outlets that are contributing to our health crisis.

How can we have allowed hospitals to get tied up in contracts with these providers—who give away some of our control of good nutrition, a fundamental tenet of health? We are giving tacit agreement that it is OK to drink a coffee that contains nine teaspoons of sugar, or a muffin that contains a quarter of our day’s recommended calories.
Why do we allow these vending machines to spew out coke and chocolate at the very patients and staff who we may well be treating for diabetes, heart disease, and knee arthritis before long—and at increasingly crippling expense too.

Let’s just go the whole hog and open a pub in the foyer too—why not? Surely our patients are sensible enough to know that we aren’t actually encouraging alcohol, just because we host outlets on the premises?

More seriously though, the NHS has made it clear to our patients and visitors that hospitals don’t condone smoking on or around our premises. When I was a trainee, I remember patients smoking on the vascular ward. Why is that different to my bariatric patients being offered chocolate and crisps from the hospital trolley while waiting for their weight loss surgery?

We can set a similar example to our anti-smoking policy with a focus on healthy eating. Why don’t we adopt an NHS policy to only commission fresh, locally sourced food to sell on our premises? What a message to give our patients: that we support the “real food” producers in our local community, not multi-million pound chains profiting at the expense of our health. Why can’t we show them that it is possible to eat delicious, fresh food, rather than the sugar-laden, heavily processed offerings that are their current choices?

Enough is enough—let’s face up to our responsibilities as a health promotion service and a role model, and actually practice what we preach. We must ensure that these new recommendations are actioned quickly and properly.

Article first published by BMJ  

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This is  Labour Party  NHS Check 9  originally published by Labour’s Shadow Health Team in 2013

Cameron’s NHS: Hospitals ‘full to bursting’

REVEALED: Hospitals across England too full and patient care put at risk

Official NHS figures for winter 2012/13 show that:

  • Every hospital trust in England operated above recommended safe occupancy levels on a least one day last winter.
  • Almost four in five hospitals filled all standard beds at one point over the winter
  • Half of hospitals filled all standard and extra beds on at least one day – not a single bed available to new patients.

Hospitals have standard ‘core’ beds and use additional ‘escalation’ beds according to demand. During the winter months the Department of Health publishes data on 159 hospital trusts, in Weekly Situation Reports, on bed occupancy levels.
All 159 hospital trusts operated above the recommended safe 85% occupancy at least once over winter. The ‘Dr Foster’ NHS performance watchdog, half Government-owned, warned that above this level quality of care can deteriorate.

The Dr Foster Hospital Guide 2012 said:
“When occupancy rates rise above 85% it can start to affect the quality of care provided to patients and the orderly running of the hospital.”2
In addition:

  • More than half of hospital trusts (86) operated at an average rate of over 95% occupancy
  • 78 trusts have experienced at least one day where there were no beds available at all
  • 27 trusts experienced 10 or more days with no standard or core beds available

Crisis in England’s A&Es

The NHS faced the worst winter in nearly a decade. At every stage of a patient’s journey, waiting times are getting longer. Patients have to wait longer for an ambulance to arrive; patients have to wait longer in ambulances, outside A&Es; patients have to wait longer in A&E before being treated; patients have to wait longer on trolleys before being admitted.

The number of patients waiting longer than four hours in A&E is almost three times higher than in Labour’s last year in office and an extra 161,890 patients waited for more than 4 hours in the last 6 months, compared with the same period last year.

Casualty waitsThere are increasing reports of long waits in A&E departments, with some patients waiting more than 12 hours to be admitted.
“Waiting times are routinely reaching 12 hours in parts of the country, while “queue nurses” have been appointed in others to watch over patients brought in by ambulance until doctors become available.
Official figures submitted by NHS trusts to the Department of Health show that 27,247 patients spent longer than four hours in an emergency department in the week ending March 17, compared with 13,200 in the same week last year.
Telegraph, 24 April 2013

Earlier this month the Norfolk and Norwich University Hospital set up a major incident tent outside its A&E as ambulances queued up outside
“A major incident tent had to be set up outside a Norfolk hospital because ambulances were left to queue outside the A&E department for hours. The mobile treatment area was set up at the Norfolk and Norwich University Hospital after 15 ambulances had to queue up on Monday. The East of England Ambulance Service said each vehicle had to wait for up to three hours to hand over patients. The hospital said demand at the A&E department had been high.
BBC News, 2 April 2013

Low staffing levels

According to the Care Quality Commission, more than 1 in 10 hospitals are operating below safe staffing levels:
“CQC also saw some improvement in staffing levels. However, this was from a low base and the providers still have some way to go. Hospital services met the standard in 89% of inspections.
Care Quality Commission, Care Update Issue 2, March 2013, p. 17

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Ed Mayo is Secretary General of Co-operatives UK.  This article was first published on his blog.

Foreword

by Peter Hunt, Chief Executive of Mutuo

NHS Foundation Trusts have made an enormous contribution to the growth of the mutual sector in the UK. They have been a vital innovation, intended to marry public service values and entrepreneurialism with a different relationship with the public. The ten years since the advent of NHS Foundation Trusts marks a decade worth celebrating, with some outstanding successes.

Mutuo has been involved throughout, by helping to share the experience of long standing co-operative and mutual businesses with new public service mutuals. Mutuals are defined by member ownership and control – and making membership meaningful is an opportunity and challenge shared by all mutuals, including long established co-ops no less than new fledgling public service mutuals. We have seen some NHS Foundation Trusts embrace the best practice of progressive mutuals, but there is a wider need to reawaken the founding intentions of Foundation Trusts and the spirit of mutuality. The legislative framework has not made it easier to do this and it is timely to consider how to deepen the democratic basis of Foundation Trusts for the next decade.

 Democratic Form for Foundation Trusts – the role of membership

To mark the ten year anniversary of the creation of NHS Foundation Trusts in England this short report sets out how we can move towards a more democratic and participative model of health care through a strengthening of the role of membership.

This could help ensure that Foundation Trusts reach the original aims that were envisioned of grass-roots membership, enabling communities to influence healthcare provision and ensuring the accountability of directors. Such a focus would be particularly timely in light of the Government’s initial response to the Francis report earlier this year, as well as the wider, ‘much-debated’ changes in the organisation of health service commissioning and provision contained in the Health and Social Care Act (2012).

Context – a co-operative vision for healthcare

NHS Foundation Trusts were created in 2003. It was a ground-breaking new legal structure called a “public benefit corporation” which was in part modelled on traditional co-operative and mutual societies. For the first time in the NHS, this introduced the concept of grass-roots membership (patients public and staff) for NHS organisations, together with a form of democratic governance. This was a break with tradition – and provided a new model which for the first time enabled communities through their elected representatives to influence healthcare provision.

The co-operative sector was supportive of Foundation Trusts from an early stage, recognising that the inspiration came in part from co-operative and mutual societies. I played a role in this personally, in a former role, contributing to the formative work on the model and chairing the Department of Health Governance Advisory Group for Foundation Trusts that developed initial guidance on models of working.

The promise that democratic engagement offers remains worthwhile. There are good examples of health co-operatives worldwide, which have been able to promote a model in which responsibility for health development lies with the citizen and they, in a group or community setting, are at the centre of action for well-being, rather than what the UK still has, which is a provider-led model of healthcare centred, above all, on acute, secondary healthcare services.

The UK does have examples of participatory co-operatives in healthcare, outside of the NHS. Benenden Healthcare, for example, has a membership of 900,000, organised in branches with a highly democratic structure. The society has been voted the UK’s most trusted healthcare provider for three years, in 2011, 2012 and 2013. But Benenden exemplifies not just satisfaction but also responsibility. The claim rate on services is significantly lower than for private health insurers, because, rather than seeing it as an individual consumer transaction, operating as a zero-sum game, Benenden members are aware that they are drawing on support that is pooled and to be shared equitably for all members according to need.

It is also important to recognise that there is a different experience over the last ten years, with its own positive lessons and cautions, from patient and public involvement in health and social care in Scotland and Wales.

The Reality – mutuality in question

Given the way in which patient focus, service quality and health development have moved into the mainstream discourse of health policy, we might expect such examples to have informed the development of NHS practice. If anything, the opposite is true. Although there are some models of good practice, most notably amongst metal health providers, the overall field of Foundation Trusts has widened but it has not deepened in terms of democratic practice and participation.

This has not been helped by the focus of the regulator and inspectors on finance and traditional NHS professional concerns, while the widening of the numbers of Foundation Trusts has not encouraged a deepening in terms of the practice or culture of mutuality. The findings of the Francis report are relevant, particularly that there was no culture of listening to patients, the failure of the Board to get a grip of its accountability and governance structure, the lack of effective engagement with patients and the public, and the lack of transparency.

I accept that the legislative framework for Foundation Trusts in terms of accountability has been somewhat compromised and clumsy from the start, lacking the clarity that would have combined genuine community accountability with a public purpose and ethos to shape operations in line with a national of resources, baselines and benchmarks.

The underlying model was a simple enough concept: members elect governors who, together with a number of other governors appointed by external bodies, appoint the chair and other non-executive directors. The non-executive directors appoint the executive directors. The board of directors runs the Trust. The council of governors hold the directors to account and represent the interests of the members and the wider public.

In practice the chain of accountability was always going to be complex. Trusts were deliberately made accountable to Parliament via the risk regulator Monitor. What’s more, the development of membership tended to be less of a priority for many trusts than the development of the governor role.

There are some important differences from a traditional  co-operative approach. In a co-operative organisation, the grass-roots members are the “owners” and its custodians. Their role is to provide the ultimate protection of the organisation, to make sure that it continues to deliver its corporate purpose. Like grass-roots members of most corporate bodies, their role is limited to:

  • approve changes to the constitution;
  • approve strategic mergers;
  • decide whether to cease trading.

It is recognised that public benefit corporations operate in a different context and that now these functions (the first two, at least) are the responsibility of the council of governors. However, the effect is to leave members with a more marginal role.

The Foundation Trust Network recognises the need to support the role of governors and develop the chain of accountability from governor to trust member to the broader public, and I welcome their consistent efforts over the years to develop guidance for trusts and build capacity for wider member and public engagement and accountability. They point me to one Foundation Trust where over ten thousand members took part in voting and to some of the creative ways in which Foundation Trusts focusing on mental health have engaged their service users through membership. These are, to be sure, examples of best practice that the wider co-operative sector can learn from, just as there are outstanding co-operatives models of governance on challenges such as gender equality, with the Co-operative Women’s Challenge, and youth participation. After all, the point about participatory governance is that its effectiveness depends on the quality of participation. This is an enduring and
persistent focus and challenge for all member-owned co-operatives and mutuals, not something somehow to be solved and then left alone.

Overall, Monitor, the regulator report that there were over two million members of Foundation Trusts in 2011/12 and in a survey of practice that over 50% of trusts say that members have influenced what they do, on issues such as communication and the development of new services. Whether members feel as if they have an influence on what the trust does is not a question though that was asked. Ultimately though, this is what matters. Democratic accountability is not just about giving an account of what you do, but whether others know that their voice is taken into account.

The role of membership

I therefore argue for a reconsideration of the membership in Foundation Trusts, which I see as now having a limited role and lacking a voice. This is a cause for concern as it has a number of consequences, including making membership a relatively uninteresting proposition, with a knock-on effect in terms of recruitment and retention. This can also make governors more exposed as they lack the support or pressure of an active membership. It could also limit the range of individuals seeking
election, thereby making it difficult for governors to represent the full community.

The hollowing out of membership has been exacerbated by the Health and Social Care Act 2012, which required certain decisions to be authorised by governors, rather than members. While the act could have strengthened the position of members, in fact it did the opposite by requiring changes to the constitution to be approved by the governors (and directors). Previously trusts could choose for constitutional changes to be approved by their members. Public benefit corporations are now different in this respect from all other corporate bodies requiring governors to approve a range of other decisions including “significant transactions”, mergers and acquisitions, and taking on or substantially increasing the amount of private work.

The act introduces for the first time a requirement for an annual meeting of its members. Whilst in principle this is a good thing, it does not really enhance the position of members because

  • The annual meeting has to be open to members of the public, so membership of the trust does not give anything additional.
  • Members themselves have no rights in a Foundation Trust other than the right to vote in elections of governors. By comparison, members of a company (shareholders), who similarly have the right to attend the annual meeting, have a number of other substantial legal rights such as the power to remove directors. This makes their right to attend the AGM and ask questions rather more substantial than the equivalent for members of the Foundation Trust.

In summary, of the three core features of co-operative membership (information, voice and representation), members of an NHS Foundation Trust have representation, but patchy information and no voice as members. The role of members is therefore minimal, and membership a relatively unattractive proposition. There is therefore no real sense of “community ownership” of a trust. This either leads to an ownership deficit, or the feeling that the governors are somehow the members.

Eight actions to strengthen membership as a form of community governance

In order to address the fact that members have representation but lack a voice, I am making an eight point set of recommendations that form a democratic membership agenda for Foundation Trusts, in line with the original spirit of the model:

 

  1. Ensure that members have a voice in ownership and governance arrangements, and, create the opportunity for more pro-active engagement with members and communities.
  2. Develop practices at the grass-roots level to reinforce  communication between members and governors,  including access to elected governors, some right of approach and dialogue, and, the ability to require feedback and updates. This will help to ensure that governors are accountable and will compel them to engage with members and the local community.
  3. Review whether members should be included in the decisions currently under the control of governors.
  4. Insist that governors have dialogue with members on the issues upon which the Health and Social Care Act now requires them to decide, and, possibly other issues such as executive pay and patient safety too.
  5. Require Foundation Trusts to publish clear forward plans to members so that people know what is coming up.
  6. Through relevant regulatory and inspection frameworks, encourage Foundation Trusts to engage with their local communities via the AGM and other member or public events on decisions that their governors are likely to have to make in the future. When Governors do have to make a decision, they should do so as representatives of their community who are responding to their communities’ wishes, rather than on their own gut-response.
  7. Take other steps to create a greater sense of ownership. These could include consideration of measures such as the requirement for two-way dialogue, responsibility around health promotion, and, escalated complaints and feedback, as well as closer connections around
    membership with the operations of HealthWatch.
  8. Engage employees more systematically as members, for example through its own constituency, following the example of the co-operative Rochdale Borough-Wide Housing. NHS staff have a stake in and can make a vital contribution to the success of any Foundation Trust.

Increasing and improving the role of members through representation and engagement will help to increase accountability, ensure that healthcare provision works for the area, and, recognises the importance of community to cost-effective and inclusive health development in years to come.

The SHA produced a discussion document on Foundation Trusts in 2010 which also contained proposals to improve accountability, involvement and democracy.

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We need a regime for financially failing Trusts – but this is not it.

The government used the existing regime in Lewisham and found that the law only applies to the failing Trust, making their unjust and unpopular plans illegal. They now want to change the law to ensure that any future Trust Special Administrator process can deal with the whole health economy as well as the failing Trust.

Justice for Lewisham Hospital

The new plans, slipped into the Care Bill and going through the Commons now, have huge implications for Clinical Commissioning Group freedoms and patient and public participation and involvement. The rules are unchanged from the previous regime (bad enough in itself). It allows for a rapid set of decisions across a potentially wide geographical area, enabling the Trust Special Administrator to reconfigure large areas at a stroke. It will include financially healthy as well as unhealthy Trusts.

The amendment is a threat to the NHS in general and accountability in particular.

Firstly, it looks better, because the time for the Trust Special Administrator is extended by giving 65, rather than 45, working days to produce the draft report and allowing 40, rather than 30, working days to undertake consultation on that report.

In the rest of the amendment, the restriction of accountability is draconian:

  • No referral to Scrutiny
  • No patient and public involvement – at all – is needed: the statutory obligations of commissioners to involve and consult patients and the public in planning and making service changes do not apply in respect of the trust special administration regime.
  • NHS England can decide on the Trust Special Administrator’s plan if local CCGs cannot agree. NHS England would have the final say.

So the restrictions on CCG decision-making are extreme:

A clinical commissioning group that commissions services from a successful NHS trust can now see local services removed, even if that clinical commissioning group considers those services to be essential.

But anyway this amendment may not work because:

Neither a CCG nor a Foundation Trust is subject to the direction-making powers of the Secretary of State. It is unclear how they are to be legally required to carry through any decision which is made within a special administration process relating to another body.

Nor is it clear what happens if the commissioners do not wish to commission services against the model that the special administrator has proposed.

We need to fight against these plans which will enable rapid and virtually unchallengeable reconfiguration across the country, cutting across CCG and public collaboration and involvement.

We need to find another way.

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According to the Regulators (Monitor, NHS Trust Development Authority and  the Care Quality Commission) just under half of our acute trusts have serious problems.  Most are made up of a single hospital plus a few bits and pieces although some have 2 or 3 hospitals in one organisation.

Sadly any rational debate about hospitals and their role within our NHS is being rapidly overtaken by real events; which bear little resemblance to anything rational.

Three things appear to be happening.  Hospitals are being subjected to major cuts through some form of “reconfiguration” process as in North West London – where amongst other changes, 4 A&E departments are to be closed.  Various flavours of failure regime are being applied to “unsustainable” Trusts, as at Mid Staffs and at South London Healthcare Trust where services are dispersed to other Trusts – which may (or may not) also involve reducing services in other Trusts which are not failing.  And all Trusts must become Foundation Trusts and so those that can’t have to merge or be “franchised” as at George Eliot and Weston Area.  More of this is on the way, maybe to a hospital near you.

This is all about having NHS hospitals within Trusts which are autonomous, independent, competing organisations which must have long term clinical and financial sustainability.

How can we make acute Trusts sustainable is the wrong question.  The real question has to be how we can get the best possible value for patients from the staff and the assets within the NHS.

Will this hospital be sustainable is also the wrong question as the answer should be – don’t know it depends on what policies are applied and on what happens elsewhere[i].

We have to think differently or give up on the NHS as we know it.

We should see a hospital not in isolation as some independent entity but as a valuable resource within a complex interconnected set of relationships.  We should not decide what a hospital should be used for without looking much wider – looking at the other resources in the locality – not just other acute provision but also within community, primary and social care.  This implies there has to be a strategic view of care provision across a wide area and some facility to deliver that view – maybe through a Health Authority or a Care Authority or a Wellbeing Board.  It is not “commissioning”.

If you ask questions about a “hospital” without the wider context you get stupid answers.  You are also almost certain to get concerted and often effective opposition, years of delay and dubious compromises which satisfy no sensible criteria.  The wider public rapidly see through the botched up “business cases” which attempt to justify cuts and closures.

We can already see the battlegrounds. Currently there are a number of small, single hospital, Trusts which are not “sustainable” as stand alone entities.  Claims that the private sector can come in and innovate the problems away should be laughed at – sadly some take this seriously.  So expect more “failures” and more “franchises”.

In a different NHS the solution would be more sensible.  You would look at needs across far more than just hospitals – perhaps even as far back as looking at why the needs are there.  Look at resources against needs over a much wider area than one hospital or one trust.  However compelling the case still take time over changes and take people with you (the public are not as stupid as policymakers assume).  Be adaptable and agile; accept that any “plan” for more than a couple of years will be torn up as policy shifts and badgers move goalposts.  Allow for staff to be employees not at one Trust but by the NHS – able to move between sites without TUPE.  Allow resources to move from one place to another to meet changes in demand, or to get the best from changes in clinical practice, without falling foul of some competition regulator.  Allow the maximum of collaboration between those that plan services and those that deliver them – don’t split them apart.

This is not about mergers as they have a dismal record in the NHS and there is precious little if any evidence of economies of scale anyway.  But it is about working and cooperating on a larger scale, and that is what the NHS could deliver if it is not ripped apart.



[i] And even this Government has been forced kicking and screaming into agreeing that the solution to the problems in one Trust will inevitably involve changes to other Trusts – changes which cannot be managed in the current policy architecture.

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Polly Toynbee in her Guardian column of 25th October draws attention to “an emergency extra law …. rushed through the Lords this week to give NHS bankruptcy administrators power over surrounding viable hospitals” (1). This means that the Government , having been told by Mr Justice Silber that the action of its appointed ‘special administrator’ to close the Lewisham  A&E department was unlawful, is attempting to change the law to allow special administrators a free hand to close facilities and move services without any real public consultation. This at a time when the Government has been heralding patient and GP involvement and engagement and supposedly bringing about a new era of localism and choice. Already this law has passed through the House of Lords and now all that stands in the way is the agreement of the House of Commons.

This Government was taking no chances. To cover the risk the House of Lords might interpret this action as a petty, vindictive, and contradictory piece of legislation, allowing backdoor reconfiguration of NHS services without going through the messy process of declaring and securing agreement to plans in advance, the Government recently replenished the well-upholstered seats of the House of Lords with a new intake of reliable voting fodder. Thus having restored the House of Lords to its traditional role as a seat of reaction, the last remaining hope is that the House of Commons will restore its reputation by standing up for due process and resisting the over-mighty executive. At least members of the House of Commons, with the prospect of a General Election in little over 18 months time, may be slightly easier to influence than the unaccountable members of the House of Lords. What are the arguments that might be used to sway MPs?

Why it should matter to Conservative MPs

The Conservative plan had been to get the dirty work out of the way early in the parliament and to be re-elected on the back of the turnaround in the economy. It certainly wasn’t to get embroiled in contentious, dubious, top-down decisions by unaccountable administrators having the effect of closing A&E departments all across the land. Even if used judiciously, 10 to 20 of these no-win situations could determine the fate of the next election.

A lot of trouble and parliamentary capital had been expended in devising a system to pass responsibility to GP commissioners not to appointed administrators. Already there were signs that GPs are disenchanted with NHS England and Monitor. This latest manipulation looks like even more top-down direction to them.

And if it is deemed permissible to hustle through legislation to get your way when due process frustrates an inconvenient delay, a dangerous precedent is created. It is all very well using parliamentary procedure to ensure the wishes of Parliament are properly enacted but it is another thing entirely to allow the executive to dictate even more and to overrule views of local GPs, patients and their MPs.

Why it should matter to Labour MPs

Yes it was the Labour Party that established the powers of the administrator within the failure regime, but this was never intended to be a backdoor means of major reconfiguration not possible through normal channels. Labour MPs should consider the risk that most of these administrative manoeuvres may be taken in Labour areas, not having friends in Cabinet. Although fighting the closure of a local hospital may help some Labour MPs be re-elected, will constituents really thank them if they are powerless to stop local services being withdrawn? Labour MPs have a duty to ensure services are defended in the interests of their constituents, and that any changes are thoroughly worked through with local people in support, not to assist NHS England to give carte blanche to help push changes through before the next election.

Why it should matter to Liberal MPs

Liberals are supposed to support localism and consensus decision-making, not to hand power to quasi-liquidators to close down much needed local services because of aberrations in NHS funding systems, struggling to cope with local pressures caused by factors outside the control of local people. For example it now seems clear that problems in South East London were caused by the unfunded consequences of PFI developments there. It may have been completely unnecessary to close the A&E and obstetric departments at Queen Mary’s Sidcup. It would surely be perverse for Liberal Democrat MPs to support an even more top-down decision-making process making it easier to override local wishes and local interests.

 Over to you Parliament

The final word should perhaps go to Professors King and Crewe from their recent book “The Blunders of Our Governments”. Summing up the causes of the many blunders of government they put the blame, amongst other things, on the failure of Parliament to do its job. It should not be the job of Parliament to make it easier for government ministers to override local concerns and to foist top-down solutions onto suspicious and sceptical local people. It should be encouraging due process, proper forward-planning and consensus decision-making. It is time Parliament stood up and made itself heard.

Roger Steer

Healthcare Audit Consultants Ltd

1. We found out this week why the government were in such a hurry when the Court of Appeal decisively rejected the appeal from the Secretary of State of the Lewisham decision.

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The NHS has been closing hospital beds steadily since 1948. On the appointed day in England and Wales the NHS took over 1,143 voluntary hospitals with some 90,000 beds, and 1,545 municipal hospitals with about 390,000 beds (including 190,000 in mental illness and mental handicap hospitals).  Now there are only about half as many beds.

In 1948 bed rest was the most widespread treatment – indeed often the only treatment – for many conditions.

It is always assumed that the first thing in any illness is to put the patient to bed. Hospital accommodation is always numbered in beds. Illness is measured by the length of time in bed. Doctors are assessed by their bedside manner. Bed is not ordered like a pill or a purge, but is assumed as the basis for all treatment. Yet we should think twice before ordering our patients to bed and realise that beneath the comfort of the blanket there lurks a host of formidable dangers.  (Dr Richard Asher, physician at the Central Middlesex Hospital, 1947)

Asher pointed to the risks of chest infection, deep vein thrombosis in the legs, bed sores, stiffening of muscles and joints, osteoporosis and, indeed, mental change and demoralisation. He ended with a parody of a well-known hymn:

Teach us to live that we may dread
Unnecessary time in bed.
Get people up and we may save
Our patients from an early grave.

Hospital Bed numbers

How do we compare with other countries?

Hospital beds per 1000 population OECD 2011

Total hospital beds, Per 1000 population

 

2011 (or nearest year)

Australia

3.8

Austria

7.7

Belgium

6.4

Canada

2.8

Chile

2.2

Czech Republic

6.8

Denmark

3.5

Estonia

5.3

Finland

5.5

France

6.4

Germany

8.3

Greece

4.9

Hungary

7.2

Iceland

3.3

Ireland

3.0

Israel

3.3

Italy

3.4

Japan

13.4

Korea

9.6

Luxembourg

5.4

Mexico

1.7

Netherlands

4.7

New Zealand

2.8

Norway

3.3

Poland

6.6

Portugal

3.4

Slovak Republic

6.1

Slovenia

4.6

Spain

3.2

Sweden

2.7

Switzerland

4.9

Turkey

2.5

United Kingdom

3.0

United States

3.1

OECD AVERAGE

4.8                       

These are OECD figures.  Thanks to John Lister for finding them

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1          Introduction Healthcare Audit Consultants

Although HS2 may at first seem unrelated, it possesses many of the features of the NHS reconfiguration debate: strong vested interests; a lot of money at stake; many people sympathetic to the vague goals of the project but without a clear idea of the costs, benefits or alternative options. Additional common features are the tendencies of the powers that be to seek to commit at an early stage; to pursue “aspiration-based planning techniques” that respond to uncertainty by the clever device of making it up or as it is called ‘adjusting to circumstances’ as the project proceeds. This is in contrast to a plan-based approach that perhaps futilely seeks to predict the future and runs the risk of being discredited and exposing project managers and sponsors to ridicule as events unfold and veer away from the predicted path.

Both HS2 and NHS reconfiguration also provide examples of governance issues, as in each case there can be top-level endorsement provided long before the case is proven and decisions have to be made. It is almost as though our leaders are in “war mode”. Faced with huge risks, massive costs, contentious benefits and the existence of easier alternatives, to ‘back-down’ is unacceptable and a sign of weakness unbecoming to someone who aspires to be a leader. Yet as we approach the anniversary of the start of WW1, as we contemplate the hubris around the collapse of RBS and the financial services industry, it seems that for government ministers the forces prompting the temptation to press the GO button outweigh the cautious forces on the side of the WAIT button.

Measured debate and due process can frustrate those who want to dive into the specifics of NHS reconfiguration proposals in a locality and who thrive in the cut and thrust of winning the arguments around the committee tables of power but the lesson drawn is there is much to be learnt from recognising similarities across government departments.

2       The National Audit Office report on HS2

The starting point for this blog is the NAO report of May 2013 ‘High Speed 2: A Review of Early Programme Preparation’  I wish simply to highlight findings and features of HS2 as discussed by the NAO, which both resonate with me and seem of relevance to the reconfiguration debate in the NHS. It is taken as read that high speed rail is a good thing but that opinion is divided as to whether the costs are worth it, the benefits big enough and whether or not better options to achieve the same objectives are not more readily available.

The NAO as part of the decision-making process was asked to review the programme and to advise Parliament. First I summarise their findings and then discuss the implications for the debate within the NHS on reconfiguration.

The key NAO findings were:

  • The Department of Transport’s strategic reasons for developing HS2 are not presented well in the business case. The ‘savings’ were not well related to the objective of ‘rebalancing regional economies’. There was limited evidence for demonstrating future capacity needs, and why alternatives were not considered to deliver capacity. It is not clear how HS2 will deliver the Department’s strategic objective of delivering/rebalancing economic growth. Major uncertainties exist in the calculations of benefits.
  • The benefit-cost ratio will change during the lifetime of the project; it was 2.4 to 1 but was now only 1.4 to 1.
  • The benefit-cost ratio calculated for phase 1 has twice contained errors and the Department has been slow to carry out its own assurance of the underlying analysis.
  • The Department and HS2 Ltd should update the data underpinning key assumptions in the benefit-cost ratio. Current calculations were found to be out of date, inaccurate and potentially misleading.
  • Project management is over-ambitious in timetabling.
  • The Department’s management and oversight of the programme must be improved.
  • The clarity of objectives must be improved. The largest quantified benefit is unclear. The Department has not structured its management and how to achieve strategic goals.
  • The Department is not sufficiently engaged with stakeholders. There are misunderstandings about approvals processes.
  • The Department has been slow to respond to issues raised by external and internal assurance. Recommendations made have still not been fully implemented.
  • Cost estimates used are still not reliable.
  • There is no mechanism to agree in-principle funding for the life of the project.
  • The NAO is concerned at the capacity to manage projects, in the light of other demands and the experience of considerable organisational change.

The NAO concluded that it could not recommend the HS2 project as value for money. Moreover the strategic need was not established. The NAO acknowledged recent work being undertaken but said it was building on a weak foundation for securing and demonstrating success in the future.

3       How is this relevant to the NHS reconfiguration debate?

The subject matter is different, the specifics unique and any comparisons with the case for reconfiguration in the NHS only of curiosity value; perhaps. On the other hand, as illustrated recently by Professors Anthony King and Ivor Crewe in ‘The Blunders of our Government’, there is a tendency amongst government agencies to display common proclivities when it comes to making claim on our resources for little apparent benefit, when other alternatives are more readily available. Thus when it comes to NHS reconfiguration there are the following common grounds for complaint.

Strategic Muddle

It is not clear that if the declared desire to improve quality is an imperative that reconfiguration is either necessary or essential. Simply implementing the European Working Time Directive would sort most problems. Nor if balancing the books is such an urgent task is it clear why spending hundreds of millions of pounds (if not billions overall) on expensive reconfiguration is the priority. The Government’s favourite consultants, McKinseys, have identified reconfiguration as potentially only delivering 7% of necessary savings and the King’s Fund concluded in its investigation of reconfiguration there would be little or no short- to medium-term savings.

There is no compelling business case

The costs of reconfiguration are often not much less than estimated benefits without there being either confidence in delivery or risks being quantified. Examples exist of early business cases containing fundamental errors, and having to be replaced by amended versions of different scope, adjusted to show a benefit, but quite different to those discussed with stakeholders at an earlier stage. There is no compelling exemplar site or unambiguously positive model for local stakeholders to be referred to.

Assurance issues remain unresolved

Issues raised by NCAT (National Clinical Advisory Team), IRP (Independent Reconfiguration Panel) and NHS strategic quality assurance processes can remain unresolved and uncertain right up to the point of public consultation and beyond.

Modelling is unconvincing

It is difficult to receive, understand and be convinced by financial and patient flow analysis of the implications of reconfiguration; for example, changes in South London only caused further problems and outcomes were markedly different to those predicted.

Approvals processes for necessary capital investment are unclear.

It is by no means certain that the Treasury will approve reconfiguration proposals prepared by the NHS. I have seen examples of business cases flouting Treasury guidance, not properly considering ‘do-minimum’ options, failing to assess total costs and failing to present a compelling business case. This for schemes and projects costing billions and at a time of national austerity.

Project management is weak

Projects typically cover a wide area, encompassing many competing independent organisations, involving multiple stakeholders, and with only vague mutual commitment. Even with the best will in the world management would always be difficult. Each reconfiguration proposal is unique, calling for local expertise, commitment and resources. These must all be in doubt.

Does this sound familiar?

4       Concluding remarks

There is much to be learnt from the HS2 affair. Boys like their trains but there comes a time in every boy’s lifetime when he must put aside childish emotions and consider objectively the business case, risks, evidence and make a balanced, informed judgement. Taking account of history, examples from other spheres of life, can all help in that judgement. I hope all those approaching the arguments for and against reconfiguration show the wisdom to make the best judgement. And I hope we will not have to read NAO reports about NHS reconfigurations in due course.

Roger Steer

Healthcare Audit Consultants

enquiries@healthaudit.co.uk

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