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.

Hospitals – keeping them open, or changing them radically.

Filed Under (Hospitals, Localities) by Paul on 30-01-2013

The last few days have seen some very important disagreements about the extent to which NHS hospitals need to be changed. Last week’s Guardian was full of the call for change from Bruce Keogh, the National Commissioning Board’s Medical Director. He took the fight to politicians by saying that by defending local interests MPs risked consigning their local hospital to “perpetual mediocrity”. Read the rest of this entry »

The NHS Confederation makes its case for a year of change in NHS hospitals

Filed Under (Clinical Commissioning Groups, Health Policy, Healthcare delivery, Hospitals, Independent Reconfiguration Panel, National Commissioning Board, Secretary of State) by Paul on 02-01-2013

The Government’s NHS reforms have done little to prevent the main change that will have to take place to ensure that our health service survives and thrives in any meaningful way in the future. That is the major reorganisation of many of the patient services that are at present delivered from NHS hospitals. In the last few days of 2012, the NHS Confederation has been putting the argument for change.   Read the rest of this entry »

Takeover: Tackling failing NHS hospitals

Filed Under (Health Policy, Hospitals, Reform of the NHS) by Paul on 01-10-2012

Last Friday a pamphlet with the above title to which I contributed was published by Reform which received some publicity in the papers and on the Today programme.

The rationale for this pamphlet will not surprise blog readers. Over the past couple of weeks I have posted on several occasions with examples of the growing clinical concerns about safety and the current configuration of hospitals. The evidence is there that the variations of outcomes that exist between hospitals are in part caused by this configuration. It will not be long before clinicians refuse to work in unsafe hospital environments. Read the rest of this entry »

More news on consolidating hospitals from the Royal College of Physicians – and another example of why the Royal Colleges will fail to set the agenda if they can’t agree.

Filed Under (Hospitals, Royal Colleges) by Paul on 25-09-2012

Yesterday I posted on published data showing wide variations in outcomes from some surgery and the Royal College of Physicians’ consultation on the future of the NHS hospital. Blog readers have brought to my attention the article in the Guardian reporting the important views of the spokesperson of the RCP Future Hospital Commission, Tim Evans. Read the rest of this entry »

Hospitals on the edge?

Filed Under (Hospitals) by Paul on 24-09-2012

The week before last the Royal College of Physicians started a consultation on the future of hospitals with the above title. The most significant thing about the document is the front page which has a cartoon of a hospital falling off a cliff and crumbling as it does so. Read the rest of this entry »

Having rewritten everything else about the NHS the Coalition Government has now rewritten the meaning of the word ‘independent’.

Filed Under (Conservative party, Health Policy, Hospitals, Independent Reconfiguration Panel) by Paul on 26-07-2012

On July 2nd the new chair of the Independent Reconfiguration Panel took up their post. Lord Ribeiro, who was between 2005 and 2008 President of the Royal College of Surgeons, is, as a top doctor, an obvious appointment. If you want someone to do something ‘independent’ then it’s obviously totally within the meaning of that word to go to a top doctor.

But look again. This is the same Lord Ribeiro who became a member of the House of Lords in December 2010 and has, since then, taken the Conservative Whip. Whether he was one before he took up his seat in the Lords on 21 December 2010, he has, since that date, been a publicly committed Conservative.

But, you might say, are not these doctors who sit in the Lords an independent bunch? Don’t they vote with their conscience and not with a Party? Isn’t he an independent first, and a Conservative second?

Luckily an organisation called “The Public Whip” keeps a record of the balance between Lord Ribiero’s independent votes against the Government and his adherence to the Conservative Whip. They have computed that there have been 157 whipped votes since he took up his seat.

The noble independent Lord has only once voted against the Conservative whip. Or to put it another way he has demonstrated his independence over party loyalty on 0.6% of the occasions when he could have done so.

Let’s not forget that during this period of time a contentious Health and Social Care Bill has gone through the House of Lords. During this period there were many pressures on doctors to vote against the Government whip in favour of a different approach to NHS reform.

But again, perhaps like many members of the House of Lords, he has been a part time politician. Perhaps these voting record figures are those of a reluctant politician who only occasionally turns up?

Another organisation called “Theyworkforyou.com” computes the number of times that Lord Ribiero has voted with his political affiliation as a % of all of the occasions upon which he was eligible to vote. They calculate this figure at 73.02% – being the percentage of occasions on which he elected to vote with the Conservative whip. They comment that “This is well above average amongst Lords”

We have the evidence that the new chair of the Independent Reconfiguration Panel has been an active Conservative.

Does this matter?

It does. For two reasons.

First you will remember that the Coalition Government has wanted to take politics out of the NHS. “We want to free NHS staff from political micro-management” said the coalition agreement in May 2010. Over and over again the Government have said that the aim of their reforms has been to remove politics from the NHS. It is therefore, at the very least, strange to appoint a person with a clear track record of party political belief to a part of the NHS that has been, up until now, independent and free from political micro-management.

So the small point is that – as in a number of areas – the Government are doing the very opposite of what they said they would do. Rather than removing politics from the NHS, this is a clear example of the way in which they are putting people with a track record of active Conservative party politics into positions of power within the NHS.

The second issue is the specific work of the Independent Reconfiguration Panel within the NHS.  Hospital reconfiguration is a profoundly political issue. At both local and national levels there are campaigns against hospital reconfiguration.

The current Secretary of State was engaged in these campaigns in the run up to the last election. Within days of his coming to power he made reconfiguration even more party political by making statements in front of hospitals – opening up parts of them. These were all in Conservative constituencies and were all opening parts of hospitals where clinicians had supported their closure.

Over the next few years everyone agrees that the pace of hospital reconfiguration must quicken. The NHS will need a larger number of radical changes to develop sustainable and safer hospital services.

For the NHS to thrive the reconfiguration process will have to be seen to work well and work cleanly.

By appointing someone with a public record of Conservative affiliation the Secretary of State has made that process much harder.

In political terms it must be the case that following the appointment of the new Chair of the Independent Reconfiguration Panel the Labour Party in the localities and nationally will be looking very closely at all of the decisions that they make.

With this chair every contentious decision becomes more contentious.      .

A very strange way for the Government to remove politics from the day-to-day running of the NHS.

PFI, failing hospitals and the question of who else was going to pay for the new hospitals that we need.

Filed Under (Hospitals, PFI) by Paul on 28-06-2012

Yesterday was the fifth anniversary of Tony Blair’s departure from Number 10 and  last night I had a small party at my place for some of us who worked for him, so it’s perhaps fitting that today’s post defends one of his health policies.

On Tuesday as South London Hospitals NHS trust was moving towards administration a number of radio journalists asked me to go on the media and talk about it. Unfortunately I didn’t have time on Tuesday but in conversations with the BBC it was clear that the Government was blaming the PFI at the hospital for the financial problems. 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.

We know the Prime Minister was in favour of unnecessary changes to the NHS – but is he in favour of the necessary changes?

Filed Under (Conservative party, Hospitals, Prime Minister, Reform of the NHS) by Paul on 04-04-2012

The Health and Social Care Bill has become an Act. This was only possible because the Prime Minister supported changes from the moment he put his name to the White Paper, through to the moment he changed his mind in April 2010, and all the way to the end of the process. It all adds up to the simple political truth that Prime Ministers get the legislation that they want through Parliament.

I suspect that if he were asked what the Bill was for he could give the ‘top line’ answer – that it gives more power to doctors and nurses. But if, over a kitchen supper, you asked him to explain how Monitor would both set prices and performance manage existing FTs, I suspect he couldn’t really give you an answer.

That wouldn’t matter so much if someone else could give an answer, but never mind – for the moment the Bill is an Act.  We know that he was in favour of something that didn’t really matter.

But what I am not clear on is where the Prime Minister stands on change in the NHS that really does matter.

Across the country there is a growing recognition that most hospitals are going to have to change the way that they deliver services, and how they are organised. The best ones are going to have to take over the worst, and as a consequence nearly all of them are going to have to change.

For example, last Friday the London Evening Standard published a page full of likely changes that will be necessary in west London over the next year or two. It involved closing A&Es and many other departments. Some local politicians were shocked at the level of these changes, but what was even more significant was an editorial supporting the changes.

This is going on all over the country.

Long term readers of my blog will remember that when the Coalition Government was formed I said that I suspected that what had been one of the major tensions within modern conservatism would play a role in the development of NHS policy. Since 1979 modern conservatism has believed both in the power of markets to improve efficiency and outcomes, and the importance of conserving institutions.

Of course these two drivers are in tension. In the Conservative-led Government of 1979-1997 markets ran through British society bringing substantial change. Whilst not many Conservatives noticed the closure of the steel and mining industries in their towns and villages, they did notice the closure of the local offices of banks, post offices and shops. All of these closures were the result of market decisions for efficiency that were at the core of the Government’s drive to change society.

Then these same Conservatives would launch campaigns against the closure of these local facilities, because not only do they believe in markets – but yes they believe in conserving as their name suggests. In the 1980s and 90s most of these campaigns, launched against the impact of their own policies, failed. Their market ‘side’ beat their conservative ‘side’.

How does this relate to the Prime Minister and his current policy toward the NHS?

At various stages in the last 18 months the Prime Minister has argued strongly that the NHS needs to change radically and that bits of markets might help bring this about. He will probably see clinically-led commissioning as something that will drive greater efficiency in the health service than the previous PCTs. He recognises that the NHS needs new drivers for efficiency.

But I wonder if he understands how that efficiency is going to hit the way the local district general hospital operates? After all as we saw in the 1980s and 90s driving efficiencies into organisations brings about changes and in many parts of the country those efficiencies meant that services were changed forever.

The consequence of greater efficiency in the NHS will be radical changes to the District General Hospital (DGH).

I think this may mean that the first half of this Parliament will see the Government arguing for greater efficiency in the NHS and the second half will see them defending the DGH against it.

But if he doesn’t make these efficiency savings, the Prime Minister will have to find more billions for the NHS to fund the inefficiency that his conservatism demands.