Posts Tagged ‘Reconfiguration’

New structures to overcome health inequalities

By Mike Broad - 5th December 2014 4:44 pm

Developing new organisational structures in the NHS must be a priority if many providers are to become sustainable and healthcare improved.

This a key finding of the government commissioned Dalton Review, which suggests that one size does not fit all when it comes to organisational structure.

The long-awaited review finds that hospital chains, Hinchingbrooke-style management franchises and Moorfields-style service level chains, federations, joint ventures and integrated care organisations, should all be considered.

Quicker transformational and transactional change is required, it says, and a dedicated implementation programme is needed to make it happen.

Ambitious organisations with a proven track record should be encouraged to expand their reach and have greater impact.

The review, led by Salford Royal Foundation Trust chief executive Sir David Dalton, suggests “new organisational responses” will be needed to remove unacceptable variation in standards across NHS providers, and to implement the new models of care supported in the NHS Five Year Forward View.

It concludes that many of the 93 trusts that have not yet reached foundation status “will not reach the required standards in their current organisational form”.

It recommends that the NHS Trust Development Authority should publish its assessment of each of those organisations’ capacity to reach FT status, the organisations’ plans, and the dates by which they will achieve FT status or another “suitable organisational form”.

The TDA would then be accountable to the Department of Health for delivering it.

The report states: “Leaders of successful organisations should become ‘system architects’, encouraged to use their entrepreneurial spirit to develop innovative organisational models and to codify and spread their success to other localities.

“Recognising these successful organisations, supporting them to develop enterprise strategies that expand their reach and developing new incentives will encourage more successful organisations to have greater impact with less successful ones.”

It further recommends that:

- the health secretary set a requirement on national NHS bodies that all transactions, such as mergers, takeovers, or franchises, should be completed in a year or less;

- Monitor and the Care Quality Commission should establish a new “credentialing” process to accredit successful organisations “capable of spreading their systems and processes to other organisations”;

- the first wave of organisations should be credentialed by October 2015.

The report concludes: “The extent of variation of standards of care across the country and the challenges all providers of NHS services face must be addressed as soon as possible.

“The NHS Five Year Forward View signposts organisations to consider new and innovative solutions to address quality and financial challenges; the recommendations of this review complement the NHS Five Year Forward View and support providers to deliver the changes required.

“Effective and speedy implementation is now required in order to have the greatest impact for patients. The government, national bodies and patients should have confidence in NHS leaders to make the necessary changes a reality.”

Read the full report.

MPs’ fears of opposition to change misplaced

By Mike Broad - 25th October 2014 10:34 am

The public are ready to support evidence-based NHS change, and want more information on health service finance to engage in ‘honest debate’

These are the key findings of an opinion poll by the NHS Confederation.

It finds that reconfiguration of local NHS services will not necessarily engender the opposition from patients and the public that politicians expect, the independent YouGov survey suggests.

More than three-quarters of those polled (76%) said they would support changes to their local NHS services if there was evidence these would improve care.

The findings contrast starkly with previous polling commissioned by the NHS Confederation, in which 43% of MPs said their constituents “would oppose changes to their local NHS”.

This survey of more than 1,500 members of the public across England, shows a significant ‘disconnect’ between local voters’ readiness to support change and politicians’ belief that backing proposed changes to health services is “political suicide”.

The survey also finds that the public’s readiness to engage in discussions about NHS reform is matched by an appetite for more information about health service finance, and a keenness for increased realism in how the issues are presented.

Key findings include:

- less than half (40%) of people thought they had enough knowledge to contribute to an open debate about the future of the NHS.

- of those who said they don’t feel they have the necessary information to contribute to an open debate about the future of the NHS, 74% said that to do so, they would need  more info on how the NHS is funded and how money is spent.

- 81% of people disagreed or strongly disagreed that politicians are honest about the future of the NHS. Among these people, the highest number of people (30%) felt that politicians are most dishonest about privatisation.

Rob Webster, chief executive of the NHS Confederation, called on politicians to harness this local support for change.

He said: “NHS and social care services must change if we are to deliver better care for patients – this is crystal clear and the evidence mounts each week. We urge politicians to take on board that the country is more than ready for them to lead the way on ensuring the NHS has room, space and permission to change.

“As we head into the final six months before the 2015 General Election, we know some candidates fear that talking about service changes could be ‘political suicide’ – but the data we are publishing today shows their constituents are far more prepared to discuss it than they might have thought.”

Reaction: NHS England’s Five Year Forward View

By Mike Broad - 23rd October 2014 10:13 am

Dr Mark Porter, chair of BMA Council

“Policymakers have tried to pretend that structural reorganisation and extending a competitive market can make up for lack of proper resourcing.

“NHS England’s Five Year View shows that you can’t, and contains a central message that the NHS needs a programme of sustained, long term investment that allows it to meet the difficult challenges that it currently faces. This is exactly what the BMA has been saying to policy makers for some time.

“When the NHS is given adequate resources it has a track record of delivering results. It is now for politicians to stop saying they understand this problem and act to give clinicians throughout the NHS the ability to deliver first rate care to patients.

“Many of the new models of working contained in these proposals could deliver benefits to patients and it is important that we look at new, flexible ways of working. As the report clearly states, the next Government must avoid another top down and expensive restructuring of the NHS that is driven by central political targets rather than local clinical priorities.”

RCP president Professor Jane Dacre

‘NHS England’s five-year plan offers several new models of care that echo the RCP Future Hospital report’s ideas of promoting integrated care and bringing care closer to the patient.

“The variety of new care models suggested in this thoughtful plan show that NHS England recognises the need for a flexible approach to providing local services, and supports integration of primary, secondary and community care much more effectively than before.

“The RCP’s recently published five point plan for the next government – Future Hospital: more than a building - asked for no top down reorganisation of the NHS, and for the removal of the financial and structural barriers to joined-up care for patients. We are therefore delighted that the plan recognises that top down reorganisation is not the way ahead, and that the default position for the NHS should be local reorganisation ideally arising from work to develop the new care models suggested in the plan.

“We also welcome the recognition of the need for transition funding to pump-prime and fast-track projects, and the awareness that the new models of care and service provision will need to be piloted and assessed for their effectiveness in improving patient care as well as reducing costs.”

Gill Bellord, director of employment relations and reward at the NHS Employers

“This is a positive programme that can help local services to adapt and plan their care in ways that are best for patients. NHS Employers looks forward to working with NHS England on this programme.

“The emphasis in developing new roles as part of improving models of care is an important one and employers will want to engage and involve their staff early in any changes. At a national level NHS Employers will work to support Health Education England in this area.

“We welcome further development around its call for new incentives to support better health and well-being, and strongly support this in principle. Effective well-being programmes are expanding rapidly in the NHS but aren’t always prominent enough in board-level planning. There is a lot of good work in the NHS around staff health and well-being and this is an area where we can - and should - act as an example for employers in other sectors.

“Employers support the continued emphasis on expanding community services, which is where the greatest gains can be made for public health, but many will want to highlight the ongoing financial strain from expanding their clinical workforce both in hospitals and the community.

“We welcome its recognition that modernising pay terms and conditions for NHS staff is necessary to reward them for the quality of the care they give, encourage new ways of working, and make the provision of services effective and sustainable seven days a week.”

David Hare, chief executive of the NHS Partners Network

“It is very welcome that NHS England recognises the importance of developing new models of care in order to protect and sustain a free at the point of use NHS. This will only be achieved by harnessing the skills and experience of all parts of the health service including independent sector providers.

“With more evidence available about the quality of NHS services delivered by the independent sector and the growing range of services being offered by independent sector providers it is clear that these organisations must play a big part in helping the NHS meet the demands of the future.

“NHS England’s renewed commitment to making good on patients’ legal right to choice is particularly welcome. Choice puts patients in control of the care they receive and when combined with meaningful comparative information enables patients to drive real improvements in the quality of local service provision.

“This issue must be put front of centre as NHS England and Monitor move to implement the proposals contained within the Five Year Forward View.”

Extra NHS funds required in next five years

By Mike Broad - 9:57 am

The NHS needs additional resources of more than 1.5% a year in real terms over the next Parliament.

The health service cannot make enough efficiency savings to bridge its projected £30bn funding gap by 2021 if its funding remains flat over the next five years.

Far from being the conclusions of a pressure group, these are the views of the NHS leadership set out in a report NHS Five year Forward View.

It’s an unprecedented warning to politicians that radical action is needed for the NHS to survive the growing pressures.

The blueprint for the next government after May’s general election sets out what the service thinks should be done between 2015 and 2020 to improve the NHS.

Even if the NHS can continue to make annual productivity gains at nearly double its long term average, its budget will be £16bn short at the end of that period.

The NHS Forward View place significant emphasis on prevention, supported self-care, improved mental health services and keeping people out of hospital.

It details new models for how care could be provided in future to deliver this. These include:

- allowing GP practices to join forces into single organisations that provide a broader range of services including those traditionally provided in hospital;

- creating new organisations that provide both GP and hospital services together with mental health, community and social care;

- helping patients needing urgent care to get the right care, at the right times in the right place by creating urgent care networks that work seven days a week;

- sustaining local hospitals where this is the best solution clinically and is affordable and has the support of local commissioners;

- concentrating services into specialist centres where there is a strong relationship between numbers of patients and the quality of care;

- improving opportunities for women to give birth outside hospital by making it easier for groups of midwives to set up NHS-funded midwifery services;

- improving  quality of life and reduce hospital bed use by providing more health and rehabilitation services in care homes;

- finding new ways to support carers by identifying them more effectively and encouraging volunteering by, for example, offering council tax reductions for those who offer help and more programmes to help carers facing a crisis

It says the next government might have to find an additional “transition fund” on top of real terms growth to introduce new models of care.

Though it says some of the money needed to “pump prime” new care models could be raised by selling off surplus NHS land and property, and by encouraging foundation trusts to spend cash sitting on their balance sheets.

NHS England’s CEO said Simon Stevens said: “The NHS is now at a crossroads – as a country we need to decide which way to go.

“It is perfectly possible to improve and sustain the NHS over the next five years in a way that the public and patients want. But to secure the future that we know is possible, the NHS needs to change substantially, and we need the support of future governments and other partners to do so.”

The Five Year Forward View is a collaboration between six leading NHS groups including Monitor, Health Education England, the NHS Trust Development Authority, Public Health England, the Care Quality Commission and NHS England.

Read the full report.

Understanding the knock-on-effects in the NHS

By Caroline Whymark - 21st August 2014 8:55 am

The fastest time for a human being to complete the Rubik’s cube is 5.55s and was set by a Belgian, Mats Valk, in 2013.

Improving the health service may take a little longer but is a bit like doing a Rubik’s cube; as soon as you make a change to solve any one facet of it, there is a degree of fallout affecting several other areas, not many of which are helpful or taken into account.

Such changes, or ‘opportunity costs’, are either ignored or not sought out so the changes made to make one aspect uniform and correct can be continued in blissful ignorance of the true extent of the collateral damage.

Further, this may not matter. If areas impacted upon adversely are not monitored, measured or part of a government target, why bother? Even when they are known about, the cost implication is usually on a different budget or for a less measurable asset - such as time.

Meeting time targets from GP referral to being seen by a specialist means additional clinics are required to prevent ‘breaching’, but what about the knock on effects from those patients’ consultations? Extra requests for scans, blood tests and operations are generated. These too must be carried out within another timeframe and present an additional resource and cost implication.

Who measures that?

You may wonder what, if any,  the impact a target of a maximum four-hour wait period in the emergency department can have on an anaesthetist but it is significant and it is not just us that are affected. Going all out to meet the four hour target puts other areas of the hospital under stress and does not always work in the patient’s best interest.

Patients with fractured neck of femur get ‘fast tracked to the ward’ so as not to be left on a trolley for hours in the ED. This is good, yet the fast tracking often involves by-passing history taking as to the cause of the fall, ascertaining the patient’s correct medication from the nursing home, doing an ECG or taking bloods.

An abnormal blood result can lie undiscovered in no man’s land until it is picked up on the pre-operative visit. However, they were out of the emergency department swiftly and up to the ward well within the four hours.

Simple orthopaedic cases and lacerations, which could be treated at the time in the emergency department, either by orthopaedics (or emergency medicine staff after orthopaedic review) are no longer managed this way. Instead of the wait for an orthopaedic review and further time to carry out the treatment, it is much easier to bandage them up and send them home with an appointment to return to the clinic the next day. So the clinics and the trauma lists fill up.

A very full daily clinic means the trauma on-call team arrive later to theatre and have less time to do more operations. Twice, I have anaesthetised patients with large hand bandages, first taken down and viewed by orthopaedics after induction of anaesthesia and remarked upon that ‘It didn’t really need a GA’ or has involved several staff murmuring ‘Is that it?’.

As well as making me mad, my concern is the harm that could come to a patient from an unnecessary general anaesthetic; anything from the discomfort of fasting and dental damage to aspiration and anaphylaxis.

I imagine the over burdening of the system is maintained by a community of  general practitioners instructed to fast track anything that could be cancer up to hospital straight away. Here 99 out of 100 lumps and bumps needlessly clog up the system required for treating the one with the actual disease effectively. Once upon a time general practitioners would prioritise referral for those most likely to need it, based on judgement and experience, but now they must meet these targets if they are to receive payment.

It seems ironic that while clinicians must remove their watches at work, the powers that be are fixated on theirs. Maybe they should relax and let doctors do what we are trained to do: triage, prioritise, refer and treat on the grounds of clinical need rather than striving to meet arbitrary targets regardless of the patient and their individual problems.

To return to the Rubik’s cube, a robot by the name of cube stormer 3 solved the whole puzzle in 3.253s, all sides correct - no one side completed at the expense of any other. It’s a pity we don’t have hospital stormer to straighten out the various facets of the health service in the same comprehensive, all encompassing  manner and of course, faster than any human being could do.

We must deliver care in new, proven ways

By Mike Broad - 4th July 2014 12:10 pm

A Health Select Committee report says the NHS is facing “one of its greatest challenges” in dealing with patients with multiple long-term conditions, such as diabetes, asthma and cardiovascular disease.

Cutting back on hospital services before community services have been developed to support people with long term conditions would be a “recipe for disaster”, MPs say.

Here’s the key reaction:

Professor Simon Bowman, president of BSR

“BSR views the publication of this report as a valuable step in raising awareness of long-term conditions, and we support the Committee’s view that government departments should work together to tackle the issue of long-term conditions management in a strategic way, and with the involvement of patients, clinicians and other stakeholders embedded  throughout.”

NHS Confederation chief executive Rob Webster

“This new report from the Health Select Committee adds further weight to the clear and growing consensus that if health and care services are to continue to meet people’s needs, we must deliver care in new ways.

“Care must be built around individuals to help them maintain good health and be independent for as long as possible. This inevitably means more emphasis on community care. There is widespread agreement among health and care professionals, clinicians and service leaders that, where clinically appropriate, this is the right approach.

“The need to change the way we deliver healthcare is unarguable.

“Transformation of the scale required cannot be done while NHS organisations are continually having to pare their finances to the bone. NHS leaders aren’t pressing the government with an open-ended demand for more money for the health service. We know money is tight across the public sector. We are calling instead for certainty. Fixed Parliaments give the opportunity for longer term settlements. A five year settlement for the NHS - or even better, a ‘decade deal’ - would give the health service certainty about its funding and enable service leaders to plan the right care for local people in the right place at the right time.

“Alongside getting the finances right, it is imperative that we change what we do and how we do it. Hand in hand with investment for transformation needs to be a genuine commitment from politicians to support the changes which are essential for the NHS’s future, and a similar commitment from the health service to be ready to change when needed.”

“Smaller NHS hospitals must change their model”

By Mike Broad - 16th June 2014 11:06 am

Small district general hospitals can survive and thrive but the way services are provided to local patients must change to guarantee quality care.

This is the finding of a report from regulator Monitor, whose economists analysed a comprehensive range of clinical and financial indicators to test whether any special factors affected the performance of hospitals with fewer than 700 beds (typically in trusts with an income of less than £300million).

The research found no clear evidence that smaller acute hospitals performed any worse clinically than larger counterparts.

However, the analysis showed that there is evidence that smaller providers may be starting to face greater financial challenges, with performance worsening more than the sector as a whole in the last two years.

The report concludes that size is likely to become more of an issue as hospitals face greater pressures to recruit staff to further improve the quality of care. Monitor recommends that the sector should:

- Identify new models of care for patients, for example re-designing services to improve the integration of care and move it closer to home

- Come up with creative ways to address the scale challenges, such as sharing staff with nearby trusts, using new technology, or building networks between smaller hospitals and major centres

- Make sure that the right balance is struck in local communities between redesigning services and making sure patients are treated near to where they live.

David Bennett, chief executive at Monitor, said: “People value their local hospitals and we wanted to understand the challenges that they face as the NHS takes on a potential £30 billion funding gap over the next decade.

“We found that smaller hospitals are facing increasing challenges but with the system’s support can continue to play an important role in the nation’s health service.

“Bigger isn’t always better and just merging or taking a ‘one size fits all’ approach to local health services is not the answer. We need to achieve the right balance between risks to quality and risks to access, and consider other constraints such as the impact of clinical specialisation to make sure patients continue to benefit from the local hospitals that they value so much.”

Terence Stephenson, chairman of the Academy of Medical Royal Colleges, said: “This is a valuable report and it has been welcome that colleges have been able to provide advice and input through the Clinical Advisory Group established for the project. Providing the right services for patients in the right place that can be financially and clinically viable is one of the NHS’s absolutely key challenges.

“It is clear from this report that that there are no simple conclusions or answers to these questions. But the report provides the service with a useful base for taking forward thinking and practical action.”

Monitor says it will now identify the new models of care that can better address the underlying causes of financial challenge at individual NHS providers and in specific local health economies. This will include understanding the economic impact of moving care out of hospital and the extent to which it might generate savings for commissioners.

Rob Webster, CEO of the NHS Confederation, said: “This important report provides additional weight to the view that we need to stop obsessing about the size of organisations and start thinking much more about models of care. Small hospitals have a future as part of a whole system approach to healthcare. Along with everyone else, small hospitals will have to adapt the range of services that they provide, and the ways in which they do so, as they continue to be part of the offer of local access to healthcare.”

Read the report.

A&E’s vital role should not be down graded

By Mike Broad - 22nd May 2014 9:59 am

Only 15% of attendees at Emergency Departments can be seen by a GP in the community without the need for Emergency Department assessment, claims research.

The research, commissioned by the College of Emergency Medicine and conducted by Candesic, finds that 85% of patients who visited A&E were there appropriately and that only one in seven attendees could have been seen within the community instead.

The college’s research significantly challenges the often quoted figure that “40% of patients who attend A&E departments are discharged requiring no treatment”.

The findings of the research arrive at a time when the delivery of emergency medicine faces a severe shortage of emergency medicine doctors, an increasing number of attendances, an unfair payment system to hospitals and a lack of accessible and effective alternatives to the Emergency Department.

Although the redirection figure of 15% is substantially less than the often quoted 40% it equates to 2.1 million attendances. This reconfirms the college’s call for the establishment of co-located Primary Care Centres - or Urgent Care Centres - to decongest Emergency Departments.

However, the difference between 15% and 40% is significant and represents around 3.5 million patients per year.

Of the 15% of people who could be seen by a GP the largest sub-group were young children presenting with symptoms of minor illness.

The group for whom redirection was least probable were the elderly.

The study finds that 22% of people could be appropriately managed by a GP working in the Emergency Department with access to the same resources.

A further 63% attendees within the Emergency Department needed the skills of a specialist emergency medicine doctor, and 28% were admitted to hospital.

The college says the data discrepancy should be viewed as an opportunity to design services fit for the future.

A&E Departments should be configured with access to co-located Primary Care Centres; GPs should work within A&E and use the Emergency Department facilities; there should be early access to specialist emergency medicine doctors.

Dr Clifford Mann, president of the College of Emergency Medicine, said: “The fact that only 15% of attendees at Emergency Departments could be safely redirected to a primary care clinician without the need for Emergency Department assessment is a statistic that must be heeded by those who wish to reconfigure services.

“Providing a more appropriate resource for the 2.1 million patients represented by this figure would substantially decongest emergency departments.

“Decongesting Emergency Departments is key to relieving the unprecedented levels of pressure placed upon them and improving patient care.”

This analysis is based on the records of 3,053 patients who visited twelve Emergency Departments across the country over a 24-hour period, and was collected on Thursday 20th March 2014 by Independent consultancy Candesic. The A&E’s were representative in terms of geography, age and case mix.

Outcomes must lead reconfiguration decisions

By Mark Newbold, CEO of the Heart of England NHS Foundation Trust - 1st May 2014 10:05 am

A new report by the Federation of Specialist Hospitals warns against compromising its members when reconfiguring services - suggesting their outcomes are among the best in England.

Dr Mark Newbold, chair of the NHS Confederation’s Hospitals Forum, comments on the findings:

“The Federation of Specialist Hospitals’ report articulates some of the concerns and recommendations voiced by our members.

“There is widespread consensus that clinical outcomes should guide any decision about reconfiguring specialised services, and evidence needs to be gathered of any efficiency gains resulting from centralising these services in fewer, larger centres.

“Any specialised services’ reconfiguration planned by NHS England must consider and address the full range of consequences. For instance, smaller providers may be destabilised if they lose specialist services, and this could impact on their ability to provide other, non-specialised, services to their communities.

“In each locality, the whole health and social care system must co-create a strategy which is appropriate for the area, and is both sustainable and capable of delivering the best outcomes for patients.

One size does not fit all, and this ‘place-based’ approach will ensure local need is taken fully into account.”

Reconfiguration: don’t cut specialist providers

By Mike Broad - 9:56 am

Plans to reorganise hospital services must recognise the unique expertise and class-leading outcomes of specialist hospital services, the Federation of Specialist Hospitals has warned.

The body is calling on NHS England to clarify its intentions regarding the reconfiguration of specialised providers in England.

The Federation cautions against a one-size-fits-all approach and emphasises the need for change to be driven by clinical considerations.

NHS England has suggested that it plans to reduce the number of providers of specialised services from 270 to 30 or fewer.

Since April 2013, NHS England is the sole direct commissioner of all specialised services with a related budget of about £13 billion, over 10% of the NHS’s total spend. Specialist hospitals carry out 250,000 procedures and 2.5 million outpatient appointments each year.

The report highlights the high performance of England’s specialist hospitals.

Professor Tim Briggs, chair of the Federation of Specialist Hospitals, said: “The Federation’s report highlights the excellent clinical and patient-reported outcomes achieved by specialist hospitals in both routine and complex services. In an NHS where the experience of the patient comes first, hospitals that deliver the best outcomes for their patients should be at the heart of the service.

“The FSH supports the reorganisation of specialised services, where there is a clear clinical rationale focused on providing high quality care. Reconfiguration of services, should concentrate provision in centres with the best outcomes for the relevant medical specialty, with appropriate sharing of this expertise through networks, rather than seeking to concentrate more services in just a few large hospitals.”

Moorfields Eye Hospital, for example, carries out about 330 drainage tube surgery procedures for intractable glaucoma each year. This involves the placement of a permanent plastic tube to allow fluid to escape from the eye. A 2012 audit found that the procedure had a success rate of 98% at Moorfields, compared to other centres where success rates are around 80%. The occurrence of complications was also significantly reduced to 3.4% at Moorfields, in contrast to 20% at some other centres.

93% of staff at The Christie who responded to the 2013 NHS staff survey reported that they would recommend the hospital to their family and friends. In a 2012 staff survey, 89% of staff at the Royal National Orthopaedic Hospital either agreed or strongly agreed that they would recommend the trust to their family and friends.  This compares favourably with the NHS staff survey national average, where only 63% of NHS staff said they would recommend treatment by their organisation to family and friends.

In December 2013, NHS England published guidance entitled Everyone Counts: Planning for Patients 2014/15 to 2018/19. This guidance included the statement of intent which anticipated the concentration of specialised services in 15 to 30 centres.

Very little information regarding these plans have been made available since the publication of the planning guidance.