Tracking everything that’s new in care models and progress of the Five Year Forward View, by integration reporter David Williams.

Hospital chains: What needs to happen next

Last week there were a number of developments around Salford and the Royal Free which, combined with the decision to increase the level of transformation funding for acute care collaboration vanguards, moved me to declare that “chains are where the action is”.

However there is still a significant amount of policy development to do on this, which is necessarily different to the ongoing work on primary and acute care systems and multispecialty community providers.

This week’s newsletter is specifically about the collaborations being developed by the Royal Free and Salford Royal, which seek to reinvent the way acute care is provided in general, rather than the chain vanguards focused on single acute specialisms such as cancer or orthopaedics.

Here are some of the big difficult questions we can expect to have firm answers to this year.

How big should a chain be?

Currently the Royal Free’s chain consists of its three main acute hospital sites plus North Middlesex Trust and a less integrated “buddying” relationship with West Hertfordshire. Salford’s chain includes Wrightington, Wigan and Leigh and Bolton as “associates”, plus Pennine Acute as a fully integrated member (it has effectively been taken over by Salford). So they’re running across about five general hospital sites each, depending on what you include.

It has been mooted in the past that chains could comprise 20 hospitals, although the Royal Free’s value proposition (its detailed business case for investment) proposes growing the chain by one member per year, eventually creating a group of 10-15 trusts, with a combined turnover of around £6bn a year. Is that the agreed destination point?

A chain of that size raises questions over how such a group would be led, whether all its members need to be neighbours, and whether anything needs to be done to speed up the process – particularly where an acquisition is needed.

How can hospital chains be established quickly?

We already know that some trusts will join chains as partners, such as Wrightington, while others will surrender their sovereignty, such as Pennine (or the old Barnet and Chase Farm Hospitals Trust). The latter type are takeovers in that they transfer agency accountability to the leading trust – but this approach has always taken many months at best, and years at worst. And they take up huge amounts of leadership energy and capacity.

If the Royal Free or Salford are going to add a hospital per year, do their leaders want to be constantly going through acquisition processes, running due diligence processes and the rest – or are there alternatives?

What will the accreditation process do?

NHS Improvement is understood to be developing a process of accreditation for trusts looking to lead a chain – a concept which might please those missing the days of an active foundation trust pipeline. It might assess organisations on the quality of their leadership, their financial viability, or their strategic plans, for instance. There is no legislative change coming, so it is unlikely this process will formally enable FTs to do anything that they cannot already do. However, what it might do is help speed up expansion, giving accredited providers a way of adding to their chains quickly without starting an onerous process from scratch every time.

An equal and opposite issue is what should be done with trusts that are unable to stand alone. Will there be any central “matchmaking” between accredited chains and struggling trusts? And how can chains be persuaded to step in to help those who need it, even if those organisations wouldn’t otherwise have been the chain’s first choice of new member?

Is competition and choice a worry?

It must be. Chains’ initial growth looks as though it will be locally focused, via a mix of takeovers and partnerships.

Even where chains grow their memberships through adding partner trusts, or via sharing of chief executives and/or chairs, rather than takeovers, the fundamental point of them is standardisation of clinical practice, with the adoption of the same care pathways on all sites within the group. The adoption of common methods to reduce variation will by definition lead to a less diverse “marketplace” – and the Competition and Markets Authority will sooner or later take an interest.

This won’t be a problem if chains are able to demonstrate the value to patients of their clinical models. But that leads us back to the earlier question about how quickly they will grow – growth will be slow if it requires going through lengthy processes to demonstrate the new pathways work. This is because improvement takes years, and also because…

How will the impact of chains be measured?

I know I bang on about this all the time (see last week’s newsletter) but the vanguards are about demonstrable improvement that can be replicated across the service. This is fiendishly difficult stuff, and acute care collaboration is less than a year old, but I am yet to see anything on how people plan to check whether a chain – or even one of its standardised clinical pathways – is good or not.

What about far flung trusts?

Competition and choice is less of an issue where a chain gains a member from further afield: if a trust in Yorkshire joined a chain centred in Wessex, as a hugely hypothetical example. But this raises a different set of challenges, particularly around leadership. How much oversight can the chain leaders in Wessex exercise over their new partners in Yorkshire? When the name of the game is adopting new clinical pathways, can this really be done remotely, without the chain’s Wessex executives and clinical directors being visible on site, working with staff in Yorkshire on implementing the new clinical model?

If that’s not possible, might chains need regional divisional leadership if they are going to have national reach? This leads neatly into another, bigger can of worms…

What is the right leadership and governance structure for a chain?

Acute hospital chains are going to be built out of the foundation trust organisational form, which wasn’t really intended to be used this way.

Imagine a scenario (again, completely hypothetical) where the Royal Free ends up heading up a chain (it prefers “group”) of 12 hospitals. Eight of these it runs itself, although only a minority are in its traditional north London patch, and four are run by other trusts.

Which sites are the FT’s governors holding it to account for, and which population are they acting on behalf of?

Meanwhile the Royal Free’s board would now have two layers of responsibility: to directly run rather more acute hospitals than any FT board currently manages, and to oversee the chain/group activities. They would own the chain’s common clinical models but would not be directly accountable for what goes on within the still-independent “partner” trusts.

A single board or is going to need to delegate a lot in order to run eight hospitals. So each site might need its own leadership team, with its own chief executive or managing director, reporting up to the chain trust’s own internal oversight functions. This would be a very operational version of the chief executive role: Very hands-on, very visible on the wards, very involved in day to day running. Meanwhile the overall trust board would have to become more strategic and less involved in front line operations.

The bigger an organisation gets, the more dispersed its leadership must become. But for that to work, accountability has to be dispersed too…

How will chain-leading FTs be inspected and rated?

Can the Care Quality Commission give a meaningful overall rating for a trust that runs lots of hospitals? Can Davids Sloman or Dalton, or whoever, reasonably be expected to assume responsibility for what goes on in every ward in every site in the group?

It might be observed that the CQC doesn’t do overall ratings for the Priory Group or Spire hospitals. If running a chain is to become attractive to the best leaders in the NHS, the CQC’s inspection regime for providers may have to become less organisation and more site-focused.