The must-read stories and debate in health policy and leadership.

The famous five

Sir David Sloman, London regional director for NHS England/Improvement since the spring, and a long-serving leader in the capital, has sought to press full steam ahead with organisational change on his patch.

On the commissioning side this has involved encouraging clinical commissioning groups to merge up to the level of their system (sustainability and transformation partnership or integrated care system) as soon as possible. This will result in five CCGs for London — a big shift from the 30-odd NHS commissioners, mainly co-terminous with local government, it has enjoyed/endured (delete to preference) for more than a decade. 

For STPs/ICS, unlike other regions, he decided to recruit chairs for all of them in one fell swoop.

On Thursday the recruits were named, and they are a not-uninteresting collection. The appointment of Marie Gabriel and Millie Bannerjee (to North East and South West London respectively), as well as coming with substantial non-executive leadership experience, will substantially increase the currently paltry racial diversity at the top of STPs and ICS.

And the appointment of Penny Dash, a senior healthcare consultant with McKinsey & Co, to North West London will raise some eyebrows, particulary of those who remember the extensive involvement of that company in providing strategic advice for that part of the world in years gone by.

Mike Cooke in North Central London, Camden Council’s chief executive until last year, gives a strong local government connection; and Richard Douglas brings top-of-the-shop credentials from his years as finance chief at the Department of Health (and indeed, currently, as an NHSE/I non-exec director) to South East London.

No-one is totally sure what an “integrated care system” is meant to be for in London, where patient flows are all over the place — nor are they, frankly, in the rest of England — but the coordinated recruitment effort, and an interesting line-up of recruits, suggest Sir David has something in mind.

Not what you expect

Cancer centres are supposed to be the hubs around which the district general hospital ‘spokes’ turn.

For a long time, the prevailing logic has been that complex work can and must be centralised at the centres of excellence with their highly specialised staff and equipment, and allied research and teaching portfolios.

So the news that clinical oncology trainees at Guy’s and St Thomas’ Foundation Trust were sometimes left to make “critical” decisions about patient care without consultant supervision is disturbing.

It suggests patients may have come to harm as a result. The trust said investigations into serious incidents in the department did not identify lack of supervision as the “root cause”, but did not clarify if it was a factor.

The issue was enough to worry the inspection team from Health Education England, and to have the trust’s very top brass show up to a follow-up meeting to discuss it.

GSTT says it has mitigated these concerns and we await HEE’s follow-up report, but there were alarming comments reported from senior staff in clinical oncology blaming the complaints from trainees on the trainees themselves rather than the department.

Perhaps GSTT just happened to receive an unusually sensitive and fault-finding batch of juniors that year, but it seems unlikely.

Whatever happened, “critical decision-making” by unsupported trainees is not what you expected from one of England’s leading cancer centres.

Hancock jumps the gun

Health and social care secretary Matt Hancock’s suggestion the four-hour target should be dropped was met with a furious reaction by senior clinicians and patient groups — and justifiably so.

The Royal College of Emergency Medicine moved swiftly to contradict Mr Hancock’s suggestion on Wednesday morning that the four-hour target should be replaced on clinical grounds.

RCEM president Katherine Henderson said: “So far… we’ve seen nothing [from NHSE’s clinical review of standards] to indicate that a viable replacement for the four-hour target exists and believe that testing should soon draw to a close.”

It is significant Dr Henderson thinks the NHSE trial of new potential new metrics should be drawn to a close, despite it not having found any evidence of a viable replacement.

She added pertinently: “Rather than focus on ways around the target, we need to get back to the business of delivering on it.”

Shortly after the college’s statement, the British Medical Association, the Society of Acute Medicine, the Royal College of Nursing and the Patients Association all waded in raising fundamental concerns about scrapping the target of their own.

The context, as ever, is critical.

When asked if the government should be judged on the NHS’ performance against the four-hour target, Mr Hancock said it should not because the standard was not clinically appropriate. Ministers, he said, should be judged on the NHS’ performance against the “right targets”.

This line of defence came less than a week after performance against the standard collapsed to a record low, as did the NHS’ performance against almost all its other core targets.

The health secretary’s comments were also made before NHSE’s clinical review of standards has made any formal recommendations — which are due in March — about whether ongoing trials have successfully developed a new target regime to replace the existing standard.

The health secretary appears to have pre-empted the review’s conclusions, which has only served to fuel long-held concerns the targets review is a “process following a decision” by those at the top that the four-hour target must go.

The four-hour target has many flaws. The decision to explore potential replacement arrangements was right. And if a better arrangement is agreed on by system leaders, clinicians and patient groups, it should be enacted.

But if the trial does not come up with a better alternative — and the evidence so far, according to RCEM, is that it has not — then scrapping the four-hour target would seem foolhardy and dangerous. It would also be seen, understandably, as an attempt to ditch the target for political expedience rather than sound clinical reasons.