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.

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