Thursday, 19 September 2013

Are super CEOs the answer for "failing hospitals"?

This morning’s piece on the BBC about getting the managers from “successful hospitals” to sort out “failing hospitals” made me feel pretty weary for a whole range of reasons.

The exercise is predicated on mortality statistics, which are increasingly and rightly being questioned, because they are simply not the robust indicators of quality that the media still persists in believing they are.  

The article predictably began with coverage of Mid Staffs that as usual presents historical anecdotal evidence as fact, with no context being given, but after five years of this, people in Stafford are pretty used to this!  

Julie Moore, who is one of the CEOs who will be parachuted in to save failing hospitals, made it clear that her starting point is that DGHs have had their day. To me that is problematic, as there are a great many people who actively question her view. It is certainly a view that needs national debate before it is allowed to re-shape our NHS by stealth.

The Interviewer took the view that it would probably be best to close down a lot of DGHs, but that this will not happen because politicians will not agree.  This analysis is simplistic, and it completely misses the point that politicians who resist hospital downgrades or closures are doing so because they represent their constituencies. Having been through the last year at Stafford, where we have been facing the active threat to our hospital, and having marched with the 50,000 who came out to support the hospital in April, I have learned a great deal about the way in which people here value their hospital and why it is important to them.  I have seen the political leaders from all parties in the borough marching side by side as a powerful response to the people of the borough. This is a process that has changed out town, for the good.

It is certainly true to say that some hospitals, probably a lot of hospitals are struggling in the current climate. The BBC article did not make any attempt to try to analyse this.  There was for instance no reference to the effects of the tariff system, where the shrinking income is forcing hospitals to concentrate treatments into larger units, in order to cover the costs. There was no mention of the way in which the tight budgetary constraints on hospitals and on commissioners are forcing hospitals to run with minimum numbers of staff, leading to increased pressure on staff, and staff burnout. There was no mention of the way in which small hospitals struggle to recruit specialists in areas where there are national shortages, and end up having to rely on expensive agency staff.

Chris Ham usefully made the point that the suggestions while far from perfect are infinitely preferable to trying to use either Management consultants or temporary CEO fixers to sort out the problems. Having seen both of these in action at Mid Staffs I would certainly agree with that.

He is right. Hospitals that are struggling need long term support, and they need access to networks of clinicians who can build a relationship with them over time.  He believes that a better option than the super heads would lie in these support networks.  I would agree with that. It is better for District General Hospitals to be working together to work out what their future role should be and how to support it, rather than being told how to act, by the leaders of super hospitals whose interests will be quite different.

Super hospitals have a role, so do District general hospitals. They are different kinds of organisations, with different functions.

Currently there are two drivers which are currently pointing the NHS in different directions.

There is the drive towards the big centres of technical excellence. These are the places to which all ambitious clinicians automatically gravitate. These centres of excellence require the surrounding hospitals to shrink and become feeders. Keeping these huge hungry hospitals functioning requires a constant stream of patients and the revenue that comes with them to feed the machine.

There is the drive towards integration, which really requires seeing hospitals in a different way, as part of a continuum of care which begins in the community, and brings Primary Community and Secondary care much closer together.  With this vision the patient, the individual, is central to the picture.  The Super hospitals are simply a part in this patient centred continuum. This is something that many people see as the future, but it really has not been explored or developed in the way that needs to happen. 

What I am seeing in Stafford now is what happens to a community where these two forces are in play.  The next few months will let us see if the combined influences of the Management consultants, the ambition of neighbouring super heads, and the way in which the politicians represent the people will help to find a solution that will satisfy the 50,000 people who marched for this hospital.
Stafford is an opportunity to reshape the NHS in a way that works for the people who use it. It needs to be seen as that.

Monday, 9 September 2013

Hospital mergers stir deep feelings.

Professor Mascie-Taylor is right to raise concerns about the element of US and Them rivalry that is now apparent in the responses to the TSA proposals.

If we look at some of the History of Hospital Mergers in the USA, which were all sparked by the drive towards centralised care, then it is clear that solutions which look perfectly sensible on an accountants spread sheet have a way of looking different when imposed on communities that have different histories and cultures and also have the natural level of rivalry that exists between neighbouring towns. Professor Mascie-Taylor drew fire for using the word “Tribal”, but it is a word that fits. It is what communities that feel under threat will naturally do.

The TSA process here has suffered from being the first in this country. The TSA have followed their brief to focus on the commercial and confidential process of finding “service providers” and I think they may reflect with hindsight that more could have been done to involve the staff, and to encourage the community to be a positive part of building a solution.

Sir Hugo understandably feels bruised by some of the heated response to the best efforts of the TSA, but if we are to work through this difficult part of the process and build a solid future for the health service in our communities it is important that he should understand why people are not willing to meekly accept that he is doing “what is best for them”.

The TSA process comes at the end of years of outside experts coming in to solve our problems. Many of these processes have had the unintended consequences of making matters worse. We are more than a little battle weary. The biggest problem that we have to deal with, as Sir Hugo correctly identifies, is the reputational damage to the hospital and the increased costs and decreased income that follow that damage.

The people of Stafford have always had their doubts about how fair this reputational damage may be, and as each new national report studies hospitals throughout the country this doubt is strengthened.  The Keogh report in particular has shown that small geographically isolated hospitals are struggling to meet the essentially political requirement for “financial sustainability” and may also struggle to recruit the skilled staff they need to perform some of the more complex medical processes. We are much clearer now that this is a real problem for small hospitals, and that is one reason why the solution for Mid Staffs matters nationally. Many people feel that this is an issue that requires national debate, and are concerned by the way in which downgrades all over the country are being hidden as “local issues”.

There is a largely unseen battle going on about what the future of the health service should look like. And Mid Staffs plays a central role in this.

There are many people who are alive now because the way in which medical skills, technology and drugs have developed with such speed over the last half century. Many people rightly see this as valuable and this drives them towards the idea of specialised super hospitals, which are hugely expensive and therefore have to be centralised. With this “Biomedical” model of the health service staff and patients need to fit the requirements of the health industry, and the health business. The TSA proposals have in fairness gone out of their way to minimise the negative effects of centralisation by ensuring that staff rotate between the networked hospitals and that as much care as possible remains in Stafford. Making this work will be a complex and difficult matter, and crucially it requires the good will of staff who will need to work together in new larger teams.

There is also a great deal of discussion and agreement about “Integration”, which really acknowledges that the technical wizardry that can be performed in acute hospitals is just a small part of what a genuine Health Service needs to do.  Integration places the acute health service within a wider picture of how do tackle preventable health problems and how do you make acute care and community based care fit seamlessly around the needs of the individual patients. This model which can be loosely described as “Bio Psycho Social” is a matter for the whole community, I saw potential support for this in  the 50,000 people who marched to support the hospital at Stafford. We are at the stage where many see “integration” as an essential way forward, but few areas have fully effective models in place.

The idea that most people would support is that you do what MUST be done centrally, and you do what CAN be done locally. If people of Stafford are shown clear evidence to support moving some processes to Stoke then I think that many can support this, especially if this is balanced by a very clear financial commitment to recognise support and develop existing teams that are doing very valuable work, and to make integrated care a reality.

Because the TSA process is a first time for all of us, it is difficult to know how far the TSA is able to listen, or to modify their proposals. I hope that that they will be able to do enough to allow the communities to support the final proposals and that they will also spend a lot of time and effort on assisting the staff and the communities to work together through the many difficult and emotive issues that face us all.

Our health service is a pact between the community and the staff who are willing to do this work.  What the staff need most of all now is certainty. It is in all our interests to find a way to make this work.