Monday, 12 August 2013

At some point we have to understand care pathways.

In Stafford we are currently facing the reconfiguration of the Health Service, through the agency of the TSA. This could set precedents for hospitals all over the country.  The verdict of the people on the receiving end of this process so far is “It is probably best not to do it this way”.

The Central question that the Trust Special administrator (TSA) has to try to answer, on the behalf of its boss Monitor, and Monitor’s boss the Secretary of State for Health is “How do we make health care financially sustainable whilst improving the quality of service?”

The most likely answer to this question is “By doing things differently”.

The challenge to the Health Service is so great that it needs a radical approach, which probably has to be centred around prevention, and integration, and also needs to take into account the issues of specialisation and the right place to perform the right tasks.

The role of the TSA in all of this is an uncomfortable one.

The TSA are here because the question is being phrased in terms of an individual hospital, which is “financially unsustainable”.  Because the question is about the future of an organisation it is probably not surprising that the proposals the TSA have made are structural. They are about what bits of the service should be performed where, and about who should commission what from where.  In the TSA's defence I am not sure what other options they had, given their remit?

The TSA do see the problem. They have had to focus on finding organisations that would offer to provide the service we need, and they see that this is not the end of the story. They know that integration plays a key role in making the future of the service work, and they know that they have not addressed it in their proposals. They are open to suggestions, and we need to help them with this.

The job of the TSA was to sort out the financial problems of one individual organisation that is part of a complex network of organisations and services. Delivering a health service and improving the quality of care depends on making “care pathways” work, and these pathways cross many boundaries.  The TSA cannot even begin to deal with this.

The TSA took a lot of stick at the first of the public consultation meetings because it emerges that they had not been to visit any of the departments whose services are now under threat. To those of us that see the importance of these services, the teams that deliver them, and the way in which they connect with the community around them this seems a very odd approach. Why would you not want to start by knowing what is there already?  To the TSA it clearly did not look like that. They needed to construct a viable structural solution from the ground up, and the existence of strong teams within the organisation were simply not relevant.

If you want to “Do things differently” then maybe beginning with what is there, the teams, how they relate to the wider health service, the way in which clinical pathways for a whole range of different conditions operate, the barriers which prevent people moving from one part of the pathway to the next, could have offered a better starting point.

We do not know what the outcome of the consultation will be, we do not know if we can make the case for the services that the TSA threatens. We are pretty certain that we can make a very strong case for ensuring that no other trust will go through a process quite like this again.

Whatever happens, when the TSA leave town we will be left with the task of trying to make a health service work for us, and if we haven’t got to grips with understanding integrated care pathways by then then this is where we will need to begin.  

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