Essential insight into England’s biggest health economy, by Ben Clover

The once and future King’s

What would it take to make King’s College Hospital Foundation Trust sustainable?

It’s worth taking another look at the future of the south London giant because its fate is so important to the configuration of services south of the river.

The question is prompted by a situation that saw it placed in financial special measures and the recent resignations of the chair, chief executive and two other directors.

What is King’s for? A sometimes unhappy mixture of specialist and district general hospital services.

The trust said capital funding would help it expand in its areas of strength.

But everyone wants capital funding – what would King’s do with it?

A lot of its Denmark Hill site is crumbling, and HSJ has written before about the trust part-funding a rebuild by building a new town on spare land.

Another idea is to take the Orpington Hospital site – the one the trust special administrator wanted to dispose of a mere five years ago – and beef it up a bit. Orpington could be the site of the south east London’s version of the South West London Elective Orthopaedic Centre, which is highly regarded by regulators, commissioners and its provider trust shareholders.

The problem with turning Orpington into an elective procedure factory is access to back up services if something goes wrong. One idea is to spend some money on providing high dependency unit style provision at Orpington to stabilise anybody who deteriorates significantly.

The idea is not at business case stage but might well be on the agenda of whoever moves into the chief executive’s chair at King’s.

Would the scheme make a dent in the £140m underlying run rate deficit? Hopefully.

There is a strain of thought in the capital that King’s needs to stop doing a fair amount of straightforward elective operations at Denmark Hill, because its emergency caseload is just too disruptive to the planned work. Some of this could profitably be sent to Orpington but not all of it can be kept inside the trust.

There is a well rehearsed debate over whether university hospitals are grossly inefficient and got away with it because of education funding or whether they are grossly underpaid by the tariff system for advanced specialist work.

High level research commissioned by the Shelford Group on one side and NHS England on the other has disagreed over this. Sadly, the debate has now come down to specific coding complaints and investigations as trusts struggle to square their 2017-18 accounts and plan for next year.

Either way, no one will disagree that the move from Project Diamond funding, which was supposed to cover the difference, to agreements with the NHS England specialised commissioning team has been problematic.

But it’s for leaders at King’s to explain why this has hit harder at Denmark Hill than elsewhere. There is a feeling in some areas that the organisation hasn’t always gone into negotiations with NHS England with the bottom up activity data that other specialists have managed.

Another local measure the trust could take is getting a better deal for some of its clinical research from King’s College London.

NHS Improvement will want to see a fair degree of reform within the trust before it looks at what it can do to put King’s back in balance.

GIRFT past the post

Getting It Right First Time is an ambitious programme to remove variation and push up quality across the hospital sector.

Sound unlikely? The programme has a budget of around £15m a year and will shortly announce regional directors who will drive it along locally.

Although relatively few formal GIRFT reports have been published so far – orthopaedics, general surgery and vascular surgery – the GIRFT teams for many other areas have been doing their site visits and making recommendations.

Many of these are already starting to change things on the ground.

For example, Chelsea and Westminster Hospital FT is looking at increasing consultant, middle grade and specialist nursing numbers in urology because its numbers did not seem appropriate to serve its population of roughly 1.2 million.

West Middlesex University Hospital, which the trust runs, does not have 24/7 urology cover. The trust is now considering centralising services at one of its two sites.

But it’s not all difficult conversations about staffing, procurement and procedures. The GIRFT report on Chelsea and Westminster’s ear, nose and throat services noted its good waiting times performance, low readmission rates and its having zero litigation claims over the past five years. The full GIRFT report on ENT will come out later this year.

There will be more GIRFT prompted change to come. Exactly how much will depend on the will in boardrooms and consultant common rooms.