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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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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.

Given that before that debate (and actually for most of the year after it) nobody really knew what the Bill was, it was the first – and only – time that a group of MPs could find an explanation of the purpose of the Bill and use it to explain their support for it.

At last a bit of a narrative!

What they were saying (hoping?) was that hospital reconfiguration would be slowed down (and stopped?) by the provisions in the Bill. The two sets of innovations – placing commissioning in the hands of GPs and the creation of local Health and Weill Being Boards – would, in their analysis, take the drive for hospital reconfiguration out of the hands of the ‘NHS bureaucrats’ and slow down changes to their hospitals.

At the time this struck me as a little naive. The belief was that since the NHS bureaucrats were the people who were organising the reconfiguration of their local hospitals and, in the experience of these MPs, were the cause of the reconfiguration then if they were taken out of the picture – and the Bill did appear to abolish them as PCTs and SHAs – then the pressure to reconfigure their hospitals would go with them.

This has proved to be wrong for three reasons.

First, over the last year as the Bill has passed through its Parliamentary stages many of the hospital services that these MPs were hoping that the Bill and their new Government would defend have been finally closed.  GPs as commissioners – rather than springing to the defence of their local hospital services that other clinicians have found were unsafe and uneconomic – have agreed that the services need reconfiguring. This has been a bit of a shock since the drive to reconfiguration was thought to be simply bureaucratic and not clinical. So it has been a surprise to see the readiness of GPs, as shadow commissioners, to continue reconfiguration.

Surprise number two will have been that whilst a number of the dreaded NHS bureaucrats at PCT and SHA level will have gone, many of the people who were leading reconfiguration from within the NHS – at PCT and SHA level – are still there. Now they are in clustered PCTs and clustered SHAS but it has become clear as the Bill has progressed they will not be abolished but will become a part of a new organisation – the National Commissioning Board.

As the Board has developed it has become clear that the vast majority of its staff will be drawn from the management of existing PCTs and SHAs. The Bill, rather than getting rid of many of the NHS bureaucrats, will entrench them in a new and powerful organisation,

Even more oddly for the anti-bureaucrat argument for the Bill, these bureaucrats will no longer be under the control of the Secretary of State. The NCB is what these MPs might call an ‘unaccountable quango’. The bureaucrats that work for it will have more power with less control by MPs and Parliament.

This wasn’t how it was meant to be.

But the third set of changes that the MPs will have realised is that not only are GPs as keen as PCTs on hospital reconfiguration, not only are NHS managers back in new and more powerful roles, but the drive for hospital reconfiguration seems to have picked up speed. The pressure for change in the configuration of NHS hospital services looks greater in January 2012 than it did as the Bill was introduced into Parliament a year ago.

One of the reasons for this was contained in the White Paper and the Bill. The Government laid down a timetable for the move of all NHS provider services into Foundation Trusts by 2014, and then there will be a lot more change. Because the Government reforms set such a target it is inevitable that hospitals and other provider trusts would begin the plans to become FTs straight away. Those hospitals that have been coasting have recognised they can only become FTs with a lot of change.

Therefore the last year has seen many plans for the closure of services and for moving them to a smaller number of sites than ever before. It has seen a record number of plans to merge hospitals and for some to be taken over by others.

Those MPs expecting the Bill to quiet down the changes in NHS hospital services and take them off of their troubling local political agenda haven been confronted with more change and with even more arguments for change further into the future..

Some of this is caused by the Government reforms arguing for a quickening of the pace to move to FT status, and some is caused by provider trusts looking closely at the economics of the next few years.

There will be more pressure for the reconfiguration of hospital services as more of those services move into FT status. FT status gives Boards the clear responsibility for their services with a new necessity for clinical and financial governance. This has led to many more organisations looking for allies or takeover and recognising that change is inevitable for the services they provide.

I have posted on this process on many previous occasions over the last year. What I want to note here – a year on from the Bill entering the House – is that for those MPs that expected the Bill to stop the reconfiguration of hospital services the Bill must be a disappointment. The pace of change in the last year, rather than being stopped by the Bill, has quickened whilst the Bill has been going through Parliament.

And if it passes, it will quicken again.

For some enthusiastic supporters of the Bill from last year this must be very puzzling indeed.

Comments:

One Response to “Implementing the Bill – Developing NHS acute provision”


  1. Paul, do you not think it is time for NHS clinicians and managers to give the politicians some more imaginative options around reconfiguration of services? The establishment in the NHS appear hostile towards small acute hospitals and offer little vision for them to flourish. The double whammy seems to be loss of ‘specialist services’ to bigger centres and loss of routine services to ‘the community’ (wherever that is). This could not be more out of step with the views of the people these hospitals serve. Real people with real opinions.

    These changes are often driven by an unquestioning belief in medical models and conjectures about the availability of specialist opinion. Fuelled by various reports from royal colleges and the like dictating what constitutes safe levels in acute settings. Not particularly famous for thinking the unthinkable, these establishment bodies frequently serve to reinforce the interests of their own members. Exhibit one – why do so many women in Holland have their babies at home with no less mortality rates than the UK? We are talking about nearly 40% compared to 2% in the UK? All our attention seems to be focused on ensuring maternity units deliver a minimum of 4000 births and we should be closing down smaller maternity units rather than actually changing the model of care. Perhaps there is something different about Dutch women and we shouldn’t worry about the continuing demarcation between obstetricians and midwives each protecting their special interests.

    Is healthcare the only industry where technology cannot take expertise to the consumer rather then the other way round?

    Large scale closure of small hospitals just ain’t going to happen. The emotional connection people have to their local hospital is so strong that we should not ignore this in the belief that they don’t understand “the evidence” or are just stuck in a nostalgia warp. I am not saying nothing needs to change and yes in some circumstances centralising clinical services might be the best thing but let’ s think more imaginatively and challenge the perceived wisdom before rushing to closure or reconfiguration. Our communities and their elected representatives deserve better quality thinking.

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