My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

Read my statement in full »

How far has the new model of local hospital provision progressed In the last year?

Filed Under (Foundation Trusts, Hospitals, Reform of the NHS) by Paul on 13-03-2014

Truthful answer?…. not very far. In two parts of London various bits of the failure regime have sounded a death knell for the old model of the local hospital, but I wouldn’t say we are a year further on in being able to explain to the public what any new model will look like.

It’s a good 18 months since the administrator argued for the breakup of South London Healthcare offering different possible solutions for different parts of the old Trust. One part was to be taken over by Kings College Hospital FT whilst another was to become a different model of local hospital.

And in October 2013 the Secretary of State (mainly) agreed to the reconfiguration proposals in North West London which amongst other changes agreed that there needed to be a new model for local hospital care in Ealing and a part of Imperial hospital.

The main thing to say about both these developments is that progress doesn’t happen quickly. My feeling is that in both locations the local trust is trying to construct its own model of the future. Of course such local ownership is a good thing, but it’s asking a lot of failing institutions to construct their own future.

And the NHS has been discussing new models of care for local hospitals for a good 15 years. This problem is not new to the NHS, nor is it something that will happen in only three or four locations.

In September 2012, in a pamphlet called The hospital is dead, long live the hospital, I suggested that there were between 20 and 30 locations where a new model would need to be created. 18 months later I would say this was an underestimate – the number is nearer 40.

The NHS has known for some time that this is going to be a sizeable problem and whilst the main performance management organisations of the NHS are concerning themselves with very many different aspects of the organisations they manage, there is no systemic, organised development of a new hospital model.

Given these organisations are spending time and effort looking into the future, the only reason such powerful bodies are not specifically developing new models of hospital must be fear.

Developing a new model of local hospital would mean publicly entering into a debate with the public about what hospitals should look like. Generally the way in which the NHS does this is pretty awful. I have read tens of documents making a case for change that begin by saying that because there is a remorseless increase in demand for healthcare there must be radical change, and when you get to the nature of the radical changes proposed they all look like cutting hospital services.

At the bare bones level the argument seems to say “The increasing demand for services is causing us some problems, so that is why we are closing your hospital.”

This is not reassuring.

The public recognise that there is rising demand for healthcare and they need some reassurance that there will be services there to meet it. They would really like these to be run by their local hospital. But the building is just an icon for them which the NHS seems obsessed with changing.

The public really do think the reasoning is strange. “Because there is much more business for the NHS we are going to close the place that does the business.”

Why not start by saying that because there is so much more business for the NHS we will be providing more services? I would think it very likely that demand and the need for healthcare will go on growing for some time and therefore we could probably start by saying that the locations where healthcare is being provided at the moment will be providing healthcare in the future. It’s just that the nature of the healthcare being provided will change.

From the point of view of the local hospital the number of patients going through their new model of care is likely to increase. But the numbers of people going through their building may decrease.

It starts with an interesting reworking of the label ‘outpatient’. At the moment outpatients have to go into the hospital for diagnosis and treatment. It’s actually quite curious that they are referred to as “out” patients.

The new model is reworked by the idea of moving outpatients to… er… outside the hospital. For this to work of course the consultants have to recognise that the bulk of their work will be outside the hospital. And this is the rub for the real change for a new model of local hospital.

Most hospital doctors (and nurses) choose to work in a hospital and not just for it. The major change in any new hospital model is to move the bulk of their work away from the fixed building that contains a load of in-patient beds. This is a radical change in the working practices of staff and will take a lot of managing.

But in financial terms the hospital can do much more business outside of the walls of the building.

That of course brings us to what is seen as the central issue – the buildings. It’s a pity that most of the people who manage hospitals seem to end up in the real estate rather than the health business. It would appear that the rate limiting factor in terms of change in the NHS has little to do with healthcare and everything to do with the fixed costs of the buildings.

And this is where leading NHS organisations could help local hospitals change their models of care.

In terms of change most other industries are more agile than the NHS because they have moved their proportion of fixed costs into the column called variable costs. In the NHS the idea of fixed costs is treated as … well… fixed. In other industries one of the main aims of policy is to gain more flexibility by moving costs into the variable column.

Individual trusts will find this hard. But collectively the NHS could tackle this by changing policy and rules.

The NHS is often disappointed when the public become fixated on the hospital building and seem less interested in services outside of that building. Yet by failing to tackle the issue of fixed costs for local hospitals, the NHS ensures that they remain fixated on buildings and not services.

So my main point is that over the last year not a lot has happened in terms of developing a new model of local hospital for the 30-40 hospitals that need to develop one. It would be good, if this blog were to report back in another year from now, for some progress to have been made.

Given the current Secretary of State isn’t playing the role outlined for his job in the reformed structure, which NHS structure is he trying to run?

Filed Under (Coalition Government, Foundation Trusts, Health and Social Care Act, Health Policy, Jeremy Hunt, Secretary of State) by Paul on 05-03-2014

The last 10 months have made it clearer and clearer that Jeremy Hunt, as Secretary of State for Health, can only do the job the way he wants to by completely ignoring the reforms of the NHS brought in by his Government.

We have one of the most activist Secretaries of State for Health of recent years  operating within a legal system – that he helped to create – which grants him very few of the powers that he feels he needs to carry out the role.

There are hundreds of Conservative party quotes attacking targets that I could use but I’ll just take one, from their 2008 document, Renewal.

“The problem is Labour’s strategy of trying to manage the NHS through top down centralised targets. These targets focus primarily on processes and administration such as stipulating the time it should take for patients to be processed through their treatment, or for administrative procedures to be completed, rather than the actual results of patient care”

Phoning up chief execs of NHS Foundation Trusts to quiz them about their A and E performance ignores several bits of the legislation that he helped to get through parliament.

He will of course remember, as he phones the CEO of an Foundation Trust, how para 1.5 of the White Paper “Liberating the NHS” (that he agreed in Cabinet in July 2010) said

“We will legislate to establish more autonomous NHS institutions with greater freedoms, clear duties and transparency in their responsibilities to patients. We will use our powers in order to devolve them”.

I am sure the CEO of the FT will feel, as he is being called by Jeremy Hunt, that he is part of a more autonomous institution…

First let’s get one issue out of the way. There are those that say that Jeremy Hunt’s job as Secretary of State for Health is made much more difficult by the fact that he has to work within a structure created by NHS reforms that reflect the ideas of his predecessor Andrew Lansley – and that he in fact had nothing to do with the structure and the law that he now chooses to ignore.

The argument goes that Andrew Lansley had a very idiosyncratic view of how the NHS should be organised and that given just how individual that was it’s hardly surprising that Jeremy Hunt needs to do something different.

This argument depends upon Andrew Lansley having acted purely as an individual who one day simply implemented his very individual plan.

But it wasn’t like that. That’s not what happened. Andrew Lansley was a member of a Cabinet that discussed his plans on several occasions – and on each occasion the Cabinet decided to go ahead with these plans.

Andrew Lansley was a Member of Parliament who belonged to the party that formed the greater part of the Government. Jeremy Hunt is a Member of Parliament who belongs to the same political party. He voted for the Health and Social Care Act on very many occasions. He signalled his agreement with Andrew Lansley’s plans by voting for them on all those occasions.

So it may be that these reforms were odd, but they were actively supported on many occasions by the Coalition Cabinet (member Jeremy Hunt) and the Conservative Party in Parliament (member Jeremy Hunt).

And my obvious point is that Jeremy Hunt was an active part of the processes that enthusiastically agreed the plans for a new NHS structure that he now ignores.

In Cabinet in July 2010 there would have been a discussion of the White Paper that specifically argued for a much smaller role for the Secretary of State in running the health service.

In Cabinet in December 2010 there would have been a discussion of the biggest Health Bill in history where clause after clause outlined how a new architecture of independent organisations would take power away from the Secretary of State.

In 2011, given the trouble that the Bill was in, there would have been several other Cabinet discussions about the Bill. In each of these the Cabinet collectively (member Jeremy Hunt) decided to go ahead with the reforms.

Jeremy Hunt was an active member of this Cabinet. He was a part of these discussions which collectively agreed to push them forward.

These reforms – which the current Secretary of State now finds it difficult to live within – were agreed personally by him over a long period of time.

They are just as much Jeremy Hunt’s reforms as they are David Cameron’s and Andrew Lansley’s.

Jeremy Hunt’s problem is that the reforms he voted for and passed into legislation created a system which now gives him insufficient power to carry out his work in the way that he feels he needs to.

You might think that the daily spectacle of a Conservative Secretary of State trying to wield powers that he personally contributed to removing from his office, would be a matter for some derision and scorn from Her Majesty’s Opposition.

There are hundreds of quotations about not making top down decisions which could be thrown across the chamber at Jeremy Hunt and contrasted with the need to intervene he seems to feel every day.

The opposition could make him a figure of fun for doing the opposite of what his legislation signed up to.

But they don’t. No one says this is weird because the opposition think that if and when they take over the role of Secretary of State for Health they will also be looking to use as much power as possible to tell people in the NHS what to do. They relish the thought of telling CEOs what they can and cannot do and are rather pleased that they don’t really seem to need legal powers to do that.

Their failure to point this out doesn’t change the rather odd nature of what is going on though.

Some arguments about political continuities and the creation of Foundation Trusts

Filed Under (BBC, Foundation Trusts) by Paul on 17-01-2013

Some commentators have been kind enough to suggest that I played a role in developing the NHS reform policy that created Foundation Trusts.

Some commentators on this blog have made the same point – only in a very different way – suggesting that this reform was the start of a process that the Tories have continued with their current reforms, and that all of this is bad for the NHS. Read the rest of this entry »

The Foundation Trust movement at 8 years old

Filed Under (Culture of the NHS, Foundation Trusts) by Paul on 24-10-2012

Today I am at the Convention Centre in Liverpool for the first ever Foundation Trust Network national conference. I’m on the platform on a couple of panels to talk about quality and regulation (of which more later). Read the rest of this entry »

Why does the new architecture of the NHS have to pretend so hard to be something else?

Filed Under (Foundation Trusts, National Commissioning Board, NTDA) by Paul on 18-07-2012

Monday saw the NHS Trust Development Authority  (NTDA) appoint its second tier of staff. Leaving aside the fact that it looks now as if the NHS is a completely closed shop – with no external advertising for what are all very important posts being filled over this month or so – there are some very good people being appointed.

As the new architecture emerges from the mist it is clear that the NTDA is really very important. Read the rest of this entry »

“No micromanagement of the NHS” was the Government’s election pledge – so how is that working out?

Filed Under (Foundation Trusts, Health and Social Care Bill, Hospitals, Manifestos, Reform of the NHS, Secretary of State) by Paul on 06-06-2012

Foreign Secretary William Hague is an experienced politician.

One would assume that over the years he has paid attention to the political manifestos upon which he has been elected.

Given that he has been in shadow cabinets – and now the cabinet – for some time one might reasonably assume that he also pays attention to their discussions about legislation.

Given also that he has been in the House of Commons for a very long time you might imagine that he looks hard at the legislation for which he is voting. Therefore when – in May 2010 – he signed off the Coalition agreement which stated that, “We want to free NHS staff from political micromanagement” we can assume that he meant it.

Similarly in December – when in Cabinet he agreed to the publication of the Health and Social Care Bill, and in January – when he voted for its second reading, we can assume that he agreed with the removal of the Secretary of State from ultimate responsibility for the NHS.

All of which makes his recent activities a bit of a puzzle.

In the Northern Echo’s 28th May edition he seems to be trying to drag the Secretary of State back into micromanaging the NHS. He has apparently had four meetings with Andrew Lansley about the loss of services at one of the hospitals in his constituency – the Friarage Hospital in Northallerton. These meetings have been to ask the Secretary of State to stop the downgrading of maternity and paediatric services at the hospital.

There are several hundred hospitals around England. Most of them are undergoing wide ranging service changes. If the Secretary of State has four meetings about each of them it’s going to take micromanagement to a new level of intervention.

The Secretary of State is famously good with detail, which is just as well because he will need to know the ward rounds of each sister to be able to hold detailed discussions with his colleagues.

William Hague will of course also remember that he voted through legislation to empower the quango, Monitor. His Friarage Hospital is a part of South Tees Hospitals which is itself a Foundation Trust. He will of course know that at the last election, and in the Act, he voted for the separation of Foundation Trusts from the powers of the Secretary of State to be almost total.

Therefore the Foreign Secretary will know that if he wants to try and save services in the Friarage his first point of call will be the Independent Board of the hospital. The second will be Monitor.

It is because William Hague voted in the way he did that the Secretary of State has no role to play.

Their meetings therefore are a bit of a puzzle.

At the time of the second reading of the Bill in January 2011 a number of Conservative and Liberal Democrat MPs made the point that if the Bill had already been law their maternity services and A and E departments would not have closed. They were wrong then, and they are wrong now.

William Hague will need to be a bit more careful about the platforms upon which he stands for election – and the Acts for which he votes.

What’s happening to the future of Foundation Trusts while the Government loses control of its health policy?

Filed Under (Foundation Trusts, Health Policy, Reform of the NHS) by Paul on 02-03-2012

The point I have been making over the last week is that whilst the Government may have a reform policy, it has lost control of its implementation. So I am sure if you asked a Government Minister what their policy is on FTs you would find that they still believe that all trusts should become one.

The political parties that form the Coalition Government both have a chequered history when it comes to NHS Foundation Trust policy. In 2002/3 when the Labour Government was developing the legislation that created them, the Conservative and the Liberal Democrat Parties voted against the legislation all the way through to its passage. Read the rest of this entry »

Implementing the Bill – Developing NHS acute provision

Filed Under (Foundation Trusts, Health and Social Care Bill, Hospitals, Reform of the NHS) by Paul on 19-01-2012

Nearly a year ago, at the end of January, during the Health and Social Care Bill second reading in the House of Commons a number of Conservative and Liberal Democrat MPs, following their briefing from Government whips, all made the same point about what they hoped from the Bill.  Each of them said that part of their local hospital had been threatened with closure – or actually been closed = and they knew that under this Bill such closures would not have happened.

That was why they were supporting the Bill. Read the rest of this entry »

The progressive argument in favour of lifting the private patient income cap for Foundation Trusts.

Filed Under (Foundation Trusts, Health Policy, Private Sector, Public Health, Reform of the NHS) by Paul on 10-01-2012

As I commented last week, I have given up waiting for the Government to make a coherent case for its reforms. So when, in late December, the Times published the story that a new amendment had been laid in the Bill to increase the level of the private patient income cap for Foundation Trusts, I did not expect too much from the Government by way of an explanation about why this was an important and necessary aspect of the whole NHS reform programme.

I was not disappointed. Read the rest of this entry »

Two recent reports confirm growing evidence that many NHS hospitals will need to be rapidly converted.

Filed Under (Foundation Trusts, Kings Fund, National Audit Office) by Paul on 14-10-2011

The Kings Fund (today) and the National Audit Office (yesterday) have both published reports underlining the fact that a growing number of NHS hospitals are in trouble. Read the rest of this entry »