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.

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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.

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