Lewishambles and Stafford and the Barricades

Accountability NHS Hospitals

The health economy in South London has been failing for some time, the merger to form South London Healthcare (SLHT) made things worse not better.   Around £1m a week was being put into subsidising SLHT, money which could be better spent elsewhere.  So an experienced NHS manager is put into the role of Trust Special Administrator (TSA).  The analysis confirms the depth of the problems – poor management, no real benefits gained from the merger, low productivity and high overheads in part due to PFI schemes.

The solution – break up the trust, improve efficiency through better management, transfer the assets (and staff) to other better performing NHS bodies, subsidise the excess costs of PFI , give interim support during transition.

But there is a problem.  Whilst two trusts earmarked to get parts of the break-up of SLHT were already Foundation Trusts (FTs) the other, Lewisham (LHT), was not. Transferring a “loss making” hospital to LHT would create a major strain; with the risk that an expanded LHT would itself fail further down the track.  So, could LHT just be left to reconfigure to get the necessary financial savings by (in part) using traditional routes to reconfiguration, taking 2 to 3 years and facing major opposition?

The TSA confronted this issue by ensuring that reconfiguration by LHT would have to take place, by spelling it out in terms of “recommendations”.  This also meant that LHT could avoid the lengthy formal processes for reconfiguration.  However, a Judge has ruled that making recommendations in respect of LHT is beyond the powers of the TSA.

In fact the TSA could have phrased his report to suggest or imply what changes would be needed and what would be expected from LHT in return for support and major expansion, but without making formal recommendations.  Since LHT are effectively managed through the Trust Development Authority they could have been bullied into compliance.

But the deal for Lewisham is on hold because of the Judicial Review decision.  The key issue is so fundamental that the DH have to appeal.  No trust really exists in isolation and any major change in one trust will impact on a number of others – so limiting the scope of the NHS failure regime to a single trust will not work.  The DH will have to win on appeal or else bring in new legislation (unless they can do it via Regulations).

On to Stafford

Meanwhile a different TSA approach is underway in Stafford.  It is clear that current high levels of clinical performance at Stafford have been achieved through comprehensive financial support, which is not sustainable. The trust is not “sustainable”.  Some services at Stafford are operating at levels of activity some consider too low.  The commissioners have said they only support continuing with a limited range of services from Stafford. Not promising.

So we have new TSA through the gang of three who have now (to no surprise) proposed downgrading the hospital, even if they have actually proposed more services than the commissioners support (I see a Judicial Review in the offing).  To say their proposals are unpopular is an understatement.

The proposals cannot be properly evaluated as there is not enough detail provided.  There is no time scales although it is obvious transition will take several years; and a lot might happen in that period!  There is no plan just a suggestion that if progress is made at Stafford, if capital investment is approved for new facilities in Stoke and if there is a following wind then University Hospital of North Staffs can have StaffordHospital transferred to them – nobody appear to know what happens to the staff involved.

It’s a pig’s breakfast of a solution and does nothing to end what is almost a decade of uncertainty around Stafford.

Tens of millions of £s have been spent on external consultancy in Stafford and implementing the proposals will rack up £ms more, to the usual suspects.  This is annoying as throughout they have done nothing of any great value.  The methodology of comparing costs with “average” costs at other settings and projecting patient flows based on questionable trends and a vague “commissioning strategy” is not very robust.  The failure to look at more imaginative solutions and the absence of any whole system analysis is no doubt due to limitations placed on the TSA role, but it makes analysis superficial.

As with Lewisham the solution depends on transferring a “failing” hospital to a trust which is not a FT and is itself in danger of failing.  So again the solution has to be founded on a reconfiguration which is hugely unpopular but which can be implemented by the TSA powers rather than going through the proper process (I see a Judicial Review).

What this should tell us is that the whole approach is bonkers.

The approach to “failing” trusts and indeed to “reconfiguration” is based on the assumption trusts can be treated as if they were independent business within some kind of market.  What both the above have shown is that whilst trusts may have some autonomy and some freedoms they are still intrinsically linked to other NHS bodies around them.  The market idea that “failure” allows a bad provider to exit and be replaced by a “good” provider is simply nonsense when applied to an acute trust.

Whilst we have this notion of competition, markets and failure and the need for trusts to be sustainable in this totally artificial microcosm then it is no surprise that attempts at reconfiguration of any kind are resisted; why should we buy into such an absurd process.  So we all campaign against closures and cut backs wrapped up as something of alleged benefit.

Until we drop the whole idea of competition and markets and of trusts as competing separate individual business units then we should oppose the service cuts and closures however they are dressed up.  We should only consider supporting reconfiguration (of either a whole trust or just some services) when it is clearly demonstrated to those who will be impacted that overall the change is in the best interests of the NHS as a whole and local communities.