As Consultants are generally intelligent folk, they ponder the sandy soil on which the original NHS castle was built. When some of them fall by the wayside, others have usually stepped in, but now there is a disengagement with the politics of health to the point where many just say “We told you so”, and don’t wish to do any more to reduce the quality of their lives and that of their families. The only reform that will make sense to patients is one that makes sense to the profession. From, admittedly, a small sample debate in West Wales BMA it appears 70% of the profession support rationing overtly – and co-payments are just one way which patients will understand.. This is better than the destructive drop out from “castles in the air”.
There is a growing sense of urgency – if not yet panic – at the Department of Health about the pace of reform in the NHS.
With overwhelming evidence (pdf) that virtually nobody in the health service believes the target of £22bn of efficiency savings has any chance of being achieved, and an underlying accumulated deficit among providers close to £2bn, the health secretary, Jeremy Hunt, is trying to hit the accelerator.
He told the Health Service Journal bluntly that there are “too many trusts as independent organisations”, and is driving providers towards the model proposed by Salford Royal foundation trust chief executive Sir David Dalton of the biggest and best providers having chains and franchises of organisations and services.
There are some brave assumptions here – that senior managers who are good at leading one organisation will be good at leading several, which doesn’t follow, and that there will be sufficient capacity and support to deliver robust improvements in clinical quality without destabilising services in the host organisation, which is far from certain. But despite the difficulties, it is vital that fast, scalable ways to spread excellence are developed.
In the rush for change, the old foundation trust model is unravelling fast. The regulatory distinction is already blurring with the merging of Monitor, which oversees foundation trusts, and the NHS Trust Development Authority responsible for non-foundation trusts into the new body NHS Improvement.
Now Hunt has stated that it is the Care Quality Commission rating, not foundation status, which is the mark of NHS quality, and proposed that foundation trust-style autonomy should be dependent on being rated good or outstanding. Trusts which achieve that could be turned into foundations “fairly promptly”, he said; the corollary being that foundations struggling with their performance might keep the badge but not the powers.
How much autonomy such “foundation-lite” trusts might actually have is questionable; if they were unable to earn foundation status under the old system then their finances are probably too unstable to support much latitude.
With all this managerial card shuffling, someone needs to consider what it will look like from the patients’ point of view. The obvious answer is confusing. If “foundation trust” can no longer be relied on as a kitemark of excellence then it is misleading to retain it. Media stories around foundations in trouble routinely refer to foundation trust status as meaning “one of the best performing hospitals” or something similar, yet people inside the NHS know that is no longer true for more than 30 institutions.
Similarly, if your local district general hospital now has some of its specialist services validated by a centre of excellence there needs to be a clear, simple way of explaining to patients what that means. From hospital quality to accident care to online and telephone information, the NHS has a knack of making healthcare provision difficult to understand. No wonder patient choice has never taken off.
Nonetheless, add together fluidity around foundation trust powers, the emergence of chains and franchises, regulators beginning to assess systems as well as institutions, and the first experiments with accountable care organisations being responsible for managing the healthcare of local populations, and a picture emerges of an NHS in which reform is gaining momentum.
Northumberland’s plan as one of NHS England’s new care model “vanguards” to establish an accountable care organisation is one of the most promising developments. Although it lacks the scale and glamour of the Manchester devolution experiment, its clear patient focus may well deliver more eye-catching outcomes in the long term. With primary care hubs working across the county seven days a week, stronger community services and better GP access, Northumberland is confident it can achieve its goal of helping local people live healthily at home for longer – exactly the sort of reform that will secure efficiencies.
One of the appealing aspects of accountable care organisations is that they hold out the promise of being wrapped round the needs of the patient rather than being yet another iteration of NHS management reform that seems distant from clinical services. That at least is a reform that patients can understand.
Dennis Cambell reports 10th September in the Guardian: NHS workplace stress could push 80% of senior doctors to early retirement: Survey of hospital consultants finds burnout and low morale are widespread as pressures escalate at health service’s frontline