The future of maternity units and the last minute review at Stafford.

We are having a review of the possibility of retaining a consultant led Maternity service at Stafford Hospital – so what does that mean?

The Secretary of State for Health essentially nodded through the TSA (Trust Special Administrators) recommendations on the future of Stafford hospital, but with one puzzling addition; The announcement of a review by NHS England into the possibility of retaining a consultant led maternity unit at the hospital. The Prime Minister has made it pretty clear that he would like this to be provided.

This small last minute addition to the recommendations matters. It matters a lot. The results of this review will determine the “direction of travel” for maternity care in this country.  

For those of us watching the process carefully it is puzzling. We do not know what the review is intended to achieve.  The first question is what is the scope of the review and how will it be conducted.

If the review simply retraces the steps of the TSA process then it is very likely that it will reach the same conclusion, and in doing so it will put at threat a large number of smaller maternity units throughout the country.  If it goes back a step further and questions in some detail some of the assumptions behind the TSA recommendations then it is possible that a review may reach a conclusion that is in line with the wishes of many communities, and the many politicians that represent them.   

To understand the question it is useful to back track on what has happened here. Stafford has been running a small maternity unit for many years. Its results and its reputation are good and it has years of detailed data to back this up. This is something that the TSA did not really take into account at all.

The numbers of people choosing to have their babies at Stafford began to fall when the hospital struggled through the years of negative publicity, even though there was never any criticism of the maternity unit.  It is very hard to judge if the numbers of women choosing to have their babies in Stafford at this very particular point in the hospitals history is a fair reflection of the potential demand from a growing population.

The numbers fell below the number of 2,500 births a year which has been elevated by the TSA process to a magical number.

The model that the TSA put forward to potential service providers pointed out that the unit was below this number, and this was sufficient to ensure that no providers made a bid to provide a consultant led maternity service. Initially the TSA took the view that there should be no more births at Stafford. They modified this in response to the public demand, leading to the offer of a midwife led maternity unit, which is better than nothing, but is not popular with the service provider and may not meet with the approval of the public. The heightened sense of risk that clearly now exists in Stafford may mean that Stafford women will remain nervous about what may appear to be a risky option. They are unlikely to have the detailed information to allow them to make a fully informed choice.

It is worth taking a look at where this magical 2,500 came from.

The NMC did research which looks at maternity units and came up with an aspirational figure of the numbers of consultant hours that should ideally be available to maternity units of different sizes.   Larger units should move closer to having 24/7 consultants, though most including the unit at Stoke which will now be the main option for Stafford women does not and probably will not have 24/7 consultant cover.

The NHS litigation authority took the aspirational figures from the NMC and came to the conclusion that level of consultant cover was a key element in safety. For the litigation authority medical errors in child birth are the basis for the most expensive claims for compensation, and it is clearly in the interests of the Litigation authority, and the hospitals that pay their premiums, to minimise risk.  The NHSLA elevated the aspirational 2,500 figure to the number of births that hospitals should have in order to provide the number of consultant hours necessary to satisfy the NHSLA requirements.

The NHSLA figures were used by the Clinical Advisory Groups (CAGs) set up by the TSA in order to set up the model that was submitted by the TSA to service providers.

The membership of the CAGs is something that perhaps the review needs to revisit.  Were the CAGs an entirely objective and representative group of clinicians, or did the majority of them already accept the centralising agenda that seems to be the fashionable “direction of travel”.  I would also like to know to what extent the members of the CAGs expected their advice to be used in the way that it was? The minutes of the CAG meetings indicate a division of opinion.

One of the questions that I asked as a part of the HEIA Health equalities impact assessment group is what would the impact of the 2,500 rule have on the many hospitals that currently have less than this number of births. I was told that this would not apply to them as they were existing units, and the Mid staffs unit because the hospital was being dissolved counted as a new unit.  This might sound reassuring to other smaller hospitals until you recognise how many of them are currently in deep financial trouble, and work out that it is only a matter of time before they are also subject to an administration process.

I also had questions to ask about the tariff for maternity. Does this actually cover the costs? Or is maternity a loss making service for a hospital to offer.

One of the things that bothered me a lot about the administration process here is that there seemed to be so little attention given to the existing units. The good or even exemplary record of the existing maternity unit was simply dismissed as irrelevant. The TSA did not choose to talk to the staff, instead relying in the “direction of travel” set by the CAGs.

As the attention of the people of Stafford turned to the fate of the Maternity and Paediatric units the issue of travel times and maternal safety became a major focus of attention. Studies conducted in the Netherlands show a correlation between travel times and risk to mothers. It is undoubtedly the case that if people are being transferred in labour to Stoke that this will be an uncomfortable and at times unsafe process for many women. There are certainly risks involved, but this may be a risk that does not impact on the NHS litigation authority in the same way as medical errors once a woman reaches a hospital does. If a mother or child dies or is harmed in transit then who is responsible for this?  

Looking at Europe we found that the large maternity units that seem to be the preferred option to the top ranking clinicians in this country are seen as actively undesirable.  2,500 births in Germany would be seen as an excessively large unit, and the 6,000 plus births that would occur if all Stafford births were shifted to Stoke would be seen as unthinkable.

I think that the review will be a test for the CCG. The CCG has I believe done its best to rise to the public interest in Health in Stafford and to begin the task of working with the public to create the right solutions for the future. The CCG stress that they are the commissioners, and they have also indicated that a “creative solution” to the current  problem may be available.  I am with them on this. I am also encouraged by the fact that the CCG are doing what the TSA failed to do and are talking to the staff in the hospital so that they can better understand the strengths of the service that is being provided now. I hope that this will help them move towards the right solution for Stafford, which may lead to the retention of an effective maternity service here.

The last minute intervention of the Prime Minister in the Stafford situation matters. He is a politician, and he therefore knows that the opinion of the voters matters. Maternity units matter.  If we are embarking on a “direction of travel” that will lead to the closure of a number of valued maternity units around the country we need to know that we are doing so for the right reason.   I hope that the review that the Prime Minister has backed will take a close look at what we actually want from our maternity units. .

 

 

 

 

The Big Question - on Hospital Downgrades

The Big Question on BBC 1 this morning took a look at Hospital downgrades.

Hospital downgrades are always contentious, and they are starting to shape up to be one of the major flash points for the next election.

The program gave us in a nutshell the key reasons why this is going to matter.  The leading contribution was from Professor Terence Stephenson.  He represents the top ranking clinicians who are driving the re-configuration of the health service.  These are the people to whom Andrew Lansley handed power over the health service with the Health and Social Care act.  Professor Stephenson is head of the royal college of Paediatricians https://www.fmlm.ac.uk/terence-stephenson and he believes strongly in the need to centralise the medical treatment of children.

We also heard from Julia Manning who is part of the “independent think tank” 2020 health which has strong links with the Conservative party and with the insurance industry. Here is an article about Ms Manning http://www.opendemocracy.net/ournhs/andrew-robertson/2020-health-working-with-lord-howe-to-make-nhs-auk-plc-asset Ms Manning is all in favour of creative thinking to do health care differently – making it fit for the challenges of this century.   

We heard from Clive Peedell. Clive is an Oncologist, who is co- founder of the NHA party and has just announced that he will be standing for election against David Cameron in Witney, making sure that the NHS will be a central issue in 2015.  Clive speaks out for the role of generalist hospitals, and calls for adequate funding of the NHS.

Caroline Molloy who is the editor of “Our NHS” http://www.opendemocracy.net/ournhs was there to speak on behalf of the many hospitals that are facing downgrades.

The program was filmed at Peterborough which is in special measures under Monitor and where it looks increasingly likely that the hospitals deep rooted financial problems may be resolved by private sector take over http://www.opendemocracy.net/ournhs/caroline-molloy/peterborough-hospital-nhs-and-britains-privatisation-racket

Perhaps no one really knew what the results of the Health and Social Care Act would be, but we are starting to find out.

The confusing process that we have just been through with the Administrators at Stafford shows how it works.   The Secretary of State has given the power over the health service to clinicians – the CCG.  If, as increasingly happens, they hit a financial problem in the management of the hospitals that they cannot resolve then this means calling in Monitor or the TDA who will involve one or more of the big 4 accountants to act as TSAs.  The Accountants take the advice of the CAGs or clinical advisory groups which are newly created bodies packed with people like Professor Stephenson. The CAGs advise the TSAs on a model of care which is appropriate for the hospital. This is generally likely to include a strong element of centralisation.   The TSA can then invite bids from care providers willing to provide the model of care that has been stipulated, for the money available. Once the bids are in – and this is a process shrouded in secrecy, there is a consultation with the public, which the TSA seems to be at liberty to brush aside.  Monitor and the Secretary of State then rubber stamp the final recommendations.

All the stages of the administration process are controlled by the administrators who appoint the various experts, and minute the meetings. 

In a process that looks like this it is unsurprising that the end result is that there is a recommendation that there should be a downgrade.

The power over the future of the NHS is now in the hands of accountants and of a small number of powerful clinicians who strongly support centralisation.

These clinicians are probably acting in what they consider to be the best interests of patients, but they are not politicians, they do not appear to have a clear idea of the major political impact that their decision will have, and they are probably unprepared for what will happen when politicians across the country begin to wake up to the scale of the threat.

There are good reasons for doing things differently in the NHS.  One of the frustrations for those communities caught up in the process of reconfiguration is that the issues have not been aired nationally.  They need to be.  To make the NHS work for the future, to gain public support for any changes that have to be made it is essential that the public are openly and honestly given the information they need in order to  choose the changes and work with the clinicians to develop the systems we need.   

The paternalistic nature of the processes we are seeing now will simply not work.

The courts will fine Mid Staffs on the Astbury case

The Courts will today decide  how much to fine Mid Staffs foundation trust for its failings in 2007 in the case of Gillian Astbury.

The timing of course will upset some people as it always inevitably seems to be the case that there is a bit of bad news about the history of Mid staffs immediately before the announcement of something to do with downgrading services.  The fine will be effectively the last chance to punish the trust before it is dissolved next week. 

The Astbury case formed one of the two main cases that were the backbone of the Mid Staffs Public Inquiry. It involves a very ill lady with complex medical needs,  including diabetes and dementia, who died because she did not get the insulin that she needed. This is of course shocking.  What did also shock me greatly is finding out how extremely common the issue of poor management of insulin in hospitals actually is. A study by Birmingham University estimated 600 deaths a year occur because of these problems, and also offered software that would help hospitals avoid missing insulin treatment, an offer that the DoH has not so far taken up.

The coverage of the story on 21 Feb 2014 by BBCR4today was very interesting.   (sorry they have not put up a clip – but it is worth taking the trouble to listen to the interview) Emma Jones, the solicitor for Leigh Day, who has been supporting her client in taking the Astbury case through the courts stressed that her client does not want there to be large fines for the hospital. They want care to improve, and other hospitals to be warned, which of course everyone wants.  

It will be interesting to see if the courts take into account the wishes of Leigh Day’s client when they announce the level of the fine.  A token amount would probably be the right answer.

The BBC picked up on the absurdity of one public body fining another, and also questioned if it was reasonable to keep the focus on Stafford for what is such a widespread problem.  The BBC also picked up on the fact that the trust continues to have difficulty in recruiting staff, in part because of the constant drip feed of bad news. 

Next week 20 nurses, volunteers, come down from Stoke, to help resolve the staffing problems at Stafford. They will be very welcome, and it should be the beginning of regular exchange of staff between the hospitals.  This is really good news. Let us hope it is the start of a bright future for Healthcare in Stafford and Stoke.

 

Looking to the Future

Today we see national headlines on the sharp increase of over 90s being taken into A&E by ambulance, over the last 3 years. http://www.theguardian.com/society/2014/jan/29/use-ambulances-over-90s-hospital  It is good that finally we are reaching a point of understanding the huge and growing problems our hospitals face. 

Here in Stafford, where we have an unusually large number of elderly people, and we road tested the wrong solutions by cutting social care beds and hospital beds at the same time, we reached this crisis a little earlier than the rest of the country. Now we can see more clearly that the root problems are national. We can see that a number of the people who do end up in A&E would be better not being there, but come because of lack of suitable alternatives. 

There is no shortage of theories on the root causes of the increase:

Most people accept that people are living longer because of better drugs, & better surgery. This is a success story, but older patients have the potential to develop a more complex mix of illness, and need a different kind of care, something we have only just began to think through.  

The Conservatives say that the problem lies with the changes to the GP contracts leading to less availability of GPs out of hours.

Fingers have been pointed at services like 111 which mean that Nursing homes phoning for help with a sick resident are frequently being advised to call an ambulance.  

Labour points to the huge cuts that have occurred to social care, which has meant that many elderly people can no longer access the support they need in their own homes, or in day care centres, and this may mean that they are more at risk of becoming severely ill. 

Personally I am pretty bored with simplistic headline points.  The reasons for system failure are complex and will vary from place to place. And the solutions need to be built on an understanding of how the different bits of the picture fit together. 

The Effects are apparent  

 

The pressure point is always A&E. 

 

The pressures in A&E make recruitment of doctors difficult or are times impossible, leading to the use of agency staff, which can be problematic, and is certainly expensive.

The bed blocking and lack of community beds leads to such problems as breaches in 4 hour waiting times, A&E closures and Ambulance waits 

Lack of beds causes inappropriate use of Intensive care beds, contributing to a national shortage of intensive care beds. 

Pressure lead to cancellations in elective surgery, causing distress or worse to sick patients.   

        

All of this shows up in the indicators that the hospitals routinely measure and in the statistics that are used to make the political weather.  

There is political pressure to seek untried radical solutions. 

The high political profile of problems with the running of A&Es leads to a natural quest for magical solutions, and therefore to the use of management consultants. Many of which are to be found in this article on the way the NHS is now being managed http://t.co/zsf9FiYsLX

 

Politically the two biggest worries are the escalating costs of A&E and acute care, and public perception.  (This interview with Jeremy Hunt http://m.hsj.co.uk/5067494.article indicates how much importance he lays on the public perception of quality)

The expert advice on how to square this circle and give better quality for less outlay, is to reduce the demand by centralising service to centres of excellence with the hope that this will discourage “unnecessary” attendances and admissions.

The theory is that Hospitals will refocus on providing  acute medical care, The hope is that patients will perceive this as a better service because they are being offered better preventative services (to be developed) and better follow on services in the community (to be developed).

There is talk of rapid response services to help keep people at home, and different forms of telecare and digital interventions to help monitor people’s conditions without them needing to travel to surgeries or hospitals. (These novel solutions are to be developed)

Who is in Charge around here?  

The NHS is still reeling from the latest reorganisation, and the different organisations are still finding their own feet. 

The roles of the CCG, the Partnership Trust, the Hospital Trust boards, the patient participation panels. the Health and Wellbeing board, The Borough Health scrutiny board, The County council Health scrutiny board, or the Joint accountability board, let alone the CQC, Monitor and NHS England are all pretty unclear, certainly to the public, and maybe to some of the participants.

Communication between organisations may be less than perfect, and may be made problematic by the fierce competition for scarce resources, and for the need to shake off blame when the cracks in this imperfect service show up. The scale of the challenge and the potential problems are covered in this article http://www.theguardian.com/healthcare-network/2014/jan/28/integrated-care-needs-people?CMP=new_1194&et_cid=53286&et_rid=8769516&Linkid=http%3a%2f%2fwww.theguardian.com%2fhealthcare-network%2f2014%2fjan%2f28%2fintegrated-care-needs-people%3fCMP%3d%%_p_cmp%%

The channels for raising complaints when there are gaps between services are unclear, which will probably result in increased caseloads for MPs and Councillors, with cases that they cannot hope to resolve.  

Are we asking the right people?

The most influential people in determining the future shape of our Health services are organisations such as Monitor, which are packed with accountants and management consultants   http://t.co/zsf9FiYsLX  

Monitor have created the Clinical advisory Groups, or CAGS, which are selected groups of clinicians. These advisors, starting with the assumption of the budgetary cuts, in meetings run and recorded  by management consultants appointed by Monitor, set out the “direction of travel” that is the road map used to determine the future of individual hospitals. 

The models that the CAGs provide to the TSAs and to CCGs considering the future of services in their areas do not always fit well with the experiences of the people delivering care on the front line.  In Stafford we were surprised when the process did not involve contact with the front line, resulting in some very inaccurate assumptions being built into the process. 

Channels of Communication between TSAs and the front line, or CCGs and the front line seem poorly travelled.

There is plenty of talk of using new technologies to improve care and bring it closer to people. Is there enough communication between the people who understand care needs and the people who understand the technologies to make this happen? 

Great Expectations. 

In a few weeks we will know, at least in outline, who is to be given the responsibility for our hospital services in Stafford. The likely outcome is that some acute care will shift to Stoke, with the promise that the majority of care will be delivered in Stafford, or potentially even closer to people’s homes. 

I would love to say that this has been such a thorough process that we will be getting the best possible solution for our community. I am unable to say that. The process has been deeply frustrating,, and few people in the community believe that it has produced the right results , but the process rolls on regardless, and the announcement by the Secretary of State will mark a new chapter in our health service. 

The population of Stafford are now far more aware of issues within the health service than the majority of the country. We are pretty wary after the last six years of “process” inflicted on the community and we will be watching carefully. 

The promises that individuals in the community will not suffer as a result of the changes will need to be kept at the front of our minds, and they will need to be met. 

How the rest of the country will view events at Stafford remains to be seen. There has been a tendency to accept the apocalyptic vision of Mid staffs presented by the papers, something that does not fit the experience of the Stafford people, and over the last few years many people in the Health community have been happy to accept Stafford as a one off, and therefore nothing to do with them. Better informed people know that this is not the case, and if the reconfiguration of Stafford goes ahead as expected then I expect many other hospitals to follow us down the path laid out by the CAGs

An Opportunity 

The Government is keen to make Stafford disappear as an issue.  Because of that they have been prepared to pump a considerable amount of money into the area in order to help the CCGs commission a service with a strong community base that will work for us, whilst at the same time complying with the “direction of travel” set by the CAGs.  If this goes forward then I think it is in the interests of all if  people with specialist knowledge of community based services share their knowledge with us. 

This is an opportunity.  We can if we set our minds to it begin to create a health service for this area that will meet the future needs of our population. We have the potential to be a blue print for the future of District General Hospitals and also for Community based health care. Achieving that is going to take determination to communicate well.

. 

We have been through a difficult few years, in which communication within the community has not always been easy. Last year 50,000 people marched in Stafford, showing an astonishing commitment to the idea of the NHS. In the year that has followed the staff of the hospital and the people who use the services have had a chance to find their voice. The energy present in the public meetings over the last year has often been on the explosive side but if it is harnessed well, it can achieve a lot.

I do not know what Jeremy Hunt will decide in the next few weeks but I do know that collectively this community has the power to build something good. I hope he will give the right signals to make that possible.  

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. http://www.bbc.co.uk/news/health-24142618

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.

 

 

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.

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.