Market Madness and Hospitals

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.