The reconfiguration of Manchester’s maternity services may have been a long time coming, but it has lessons for the rest of the country, finds Crispin Dowler.
When the neonatal intensive care unit and maternity services at Salford Royal Foundation Trust finally closed in November, it seemed almost to pass without comment. Local papers did not report angry protests. There were no indignant statements in Parliament. You would not have known that a few years previously the closure was so controversial a serving cabinet minister – Hazel Blears – joined a demonstration against it.
By the end of 2011-12 the Making it Better reconfiguration of maternity, neonatal and paediatric services across Greater Manchester will have closed four hospitals’ inpatient maternity units. It has also increased the amount spent on staffing the services by £10m a year, introduced new community children’s nurse teams, and will open new neonatal intensive care units at two hospitals. And it has been contested at every step.
From the point Manchester’s clinicians agreed they had too many inpatient maternity units, it has taken more than a decade for a plan to be cultivated and show results. Nevertheless, it has borne fruit, overcoming obstacles that often make NHS service change seem impossible: opposing provider interests, local opposition, logistical complexity and political intervention.
So, as the financial crisis stokes a growing clamour for the NHS to tackle reconfiguration, what can Making it Better teach us about making it possible?
The first thing – clearly – is that it takes a long time. “I thought going through the public consultation was going to be the most difficult part of the process,” says Leila Williams, director of the Greater Manchester Children, Young People and Families’ NHS Network. “That was, with hindsight, extremely naive. It’s taken us almost five years to implement something it took us five years to consult on, and that was not as I had envisaged it.”
State of flux
The problem, in part, was attempting major service changes in an organisation that was constantly being changed. The consultation came during the “last-but-one major restructure” of the health service, explains Ms Williams. Senior staff moved posts, new organisations formed, new targets were set and it was hard for the network to get Making it Better “up the priority list”.
Meanwhile the reconfiguration had to clear hurdles set by politicians on all sides. Under the Labour government it was referred in 2007 for a nine month review by the Independent Reconfiguration Panel. Then when Andrew Lansley became health secretary in 2010 he intervened a second time – when the network had already begun transferring services – to put it through his own “four tests” for reconfiguration.
Most people involved in Making it Better say the key to getting over these hurdles was clinical involvement.
Ms Williams concedes five years was a long time to develop a clinical model, but believes this was also their main strength.
“If we hadn’t spent that time, and had a clinical model that wasn’t robust, then – quite rightly – [at] the first or second challenge, we wouldn’t have been able to overcome it,” she argues. “We have a robust clinical model that the clinicians themselves developed and they’ve been, therefore, quite proactive in defending and promoting it.”
The first step, says Michael Maresh, clinical lead for the Greater Manchester maternity network, was getting clinicians from all affected hospitals around the table. When the obstetrics and midwifery heads of 12 Manchester maternity units met in 2000 they agreed “almost from day one” they had too many sites, he recalls.
They feared national shortages of specialist staff, increased clinical specialisation, and EU restrictions on trainee doctors’ hours would make it impossible to keep that many units adequately staffed. None, of course, particularly wanted their own units to close. But over time they were able to agree there should be eight at most, and to present a choice of possible configurations.
Dr Maresh believes he was lucky they could take that first step. “I got agreement from the clinical heads of all the maternity units in Greater Manchester that units had to close,” he says. “That ethos does not exist in certain parts of the country. As far as I’m aware there are places where hospitals refuse to accept that, because they know that if they do they’re going to be the ones who close.”
As vital as it was, clinical consensus alone was not enough, according to Mike Burrows, chief executive of the NHS Greater Manchester cluster of primary care trusts. For him, the point at which the project “became real” was when the city’s PCTs formed the joint committee that would take the final decision. It was important, he says, that this group was commissioners alone.
“One of the issues that has dogged Greater Manchester in terms of our ability to make significant service change within hospital services is that we’ve tried to adopt a kind of ‘buy-in of all’ approach. That’s fine when you’ve got fair weather, but when difficult decisions need to be taken provider organisations tend to bail out. We’ve all got scars in Greater Manchester from a couple of issues where this has occurred.”
Salford Royal Foundation Trust’s management was “devastated” when it learned its services would be among those to go, according to the trust’s chief executive David Dalton. It had believed it was in a strong position having, at the time, one of just three neonatal ICUs in the North West. For as long as he felt it was reasonable, Mr Dalton pushed its case with the commissioners and the independent review. Ultimately, however, he believes it was better for Salford to lose its services than for the reconfiguration to be thwarted.
“Of course we’re disappointed, but I entirely accept the commissioners’ rationale, the criteria they used, and that they have to take decisions which are difficult,” he says. “I prefer people to be able to take decisions openly and then stick with them. I think one of the problems we have in the health service is that hospitals tend to spend so long contesting the retention of the status quo that improvement isn’t achieved.”
After the final decision was reached, providers’ commitment to the process remained critical, explains Frank Burns, former chief executive of Wirral University Teaching Hospital. Mr Burns was brought in as a “trusted mediator” between hospital chief executives after the plan was agreed. Success, he explains, required close cooperation between trusts to deliver a centrally driven plan, and that was “to some degree counter to the culture of a service where patient choice and provider competition is the emerging vehicle for service improvement”.
Although the overall project had a mandate, “the sheer volume of detail associated with implementation creates many points of friction between trusts, and my role is to get involved where these have escalated to a potential standoff at chief executive level,” he says.
For him, the biggest challenge has been keeping the reconfiguration faithful to its “original democratic mandate” while the NHS adjusts to financial constraints that are “unrecognisable compared with five years ago”.
He gives the example of one hospital where inpatient maternity services were to close, but the local community had been promised a new standalone midwife-led unit in its place. When the provider produced its cost estimates for hosting the service, they came to “substantially more” than the local PCT had budgeted for.
Mr Burns had to broker a deal where costs above NHS tariff prices were split between the commissioner, the provider and the host trust. What made this possible, he says, was “a shared understanding that the PCT had made an absolute commitment to its population” and “the scale of financial compromise necessary could not justify loss of such a key service”.
Pay more, get more
Mr Burns’ example points to another factor that made Making it Better possible – money. In favour of their assertion that the reconfiguration was about care quality, not cost savings, its advocates had a killer point: the reconfigured services would cost more, not less.
According to the Children, Young People and Families’ NHS Network, commissioners have made recurrent investments of an additional £10m a year on staff and skills maintenance and will spend £29m over the life of the project on one off costs like transitional payments to help those hospitals that lost services adjust to the loss of income.
So, considering the time and money invested in bringing about Making it Better, what chance is there for future reconfigurations in a health service short on both? Ms Williams, now NHS Greater Manchester director of service transformation, believes it can be done more quickly, and that the service has learned a lot from the reconfigurations in London, Manchester and elsewhere.
“If we did Making it Better again it wouldn’t take us 11 years,” she says. Mr Burns argues it “isn’t inevitable implementation will always require additional investment”.
“In any event,” he adds, “the NHS still has an overall budget of £100bn, and no objective person in the service would deny there remains scope for radical changes to models of care that will yield quality improvements and better value for money. Inevitably, the more radical changes and bigger gains will be at the strategic level –maintaining or developing a mechanism for driving these changes in the future is critical.”
‘A stronger, shared vision’
The massive commitment from all the organisations involved have helped improve Manchester’s services, claim Alex Heritage and Sue Wallis.
Initiated by the largest consultation in NHS history, involving nearly quarter of a million responses, Making it Better is a regional reconfiguration of maternity, neonatal and children’s services across Greater Manchester.
The regionwide new model of care, designed to improve the safety and sustainability of services, comprises: an increased emphasis on care closer to home; a reduction in the number of inpatient paediatric, maternity and neonatal units from 12 to eight; and the relocation and development of a third neonatal intensive care unit (see diagram).
The programme is nearing completion in a five-year implementation plan. Inpatient maternity, neonatal and paediatric units in Trafford and Rochdale have closed, and staff and services have relocated to neighbouring hospitals. Daytime services remain on these sites. In November Salford inpatient maternity and neonatal services were also decommissioned; those in Bury follow suit this month.
Keeping 10 primary care trusts and eight acute NHS and foundation trusts on the same track is no mean feat. At the centre of the programme’s success is collaborative working between clinicians and managers from all the organisations involved. Greater Manchester’s clinical networks for paediatrics, obstetrics, neonatology and their respective clinical leads have been central to developing and maintaining a shared vision for Making it Better. Their role in designing its model of care has created ownership of the service changes that now affect their own organisations.
The Making it Better model of care is based on best practice, clinical guidelines and policy. Moreover, our early work has influenced Royal College of Paediatrics and Child Health policy and helped inform national thinking.
Recognition of the need for robust data from provider organisations has led to the development of new performance dashboards and a growing data collection and analysis function within the programme office. A lack of focus on this data at the start of the programme has resulted in some problems analysing the results of our efforts. Working with providers to capture the data we now know we need continues to be a challenge that has been helped by mature working relationships developed during the course of the scheme.
Robust project management arrangements are critical to a programme of this size. Detailed project plans, which are owned and used by all organisations involved and based on established methodologies, help to keep working groups focused on priority actions. The plans have needed to be flexible, and have been reshaped for different stages of the programme while remaining visible and “live” for all parties. Simple traffic light monitoring of actions – red, amber, green – has served to focus attention.
The 20 NHS organisations involved have given massive commitment to the Making it Better programme. While the plans help steer what is becoming a well oiled machine, much of the in-depth planning and operational detail required for such complex service changes – both within and between the 10 provider organisations involved – is undertaken by acute and PCT colleagues. Those organisations most affected by the changes have invested significantly in the programme with dedicated project managers supported by their own clinicians.
Governance arrangements have needed to involve the right people at the right level for decision making. Chief executives’ involvement has been critical, achieved via membership of the central programme board, regular one-to-one contact and the Greater Manchester chief executives’ forum, facilitated by NHS North West, the programme’s sponsor.
Each stage of the programme has provided an opportunity to improve the next – the closure of the first inpatient units provided valuable learning to inform the second. The policies and practices developed have been used and improved as we gain valuable experience.
The Making it Better team, and all involved, strive to implement the changes in a way that minimises the impact on the staff and families affected. Innovative human resources practices have smoothed the way, resulting in normal levels of staff turnover. However, this remains a constant challenge.
Strong, simple messages are essential – no easy task when up against the easy headlines of “cuts” and “closures”. The importance of a powerful clinical voice was recognised early and consistent coordinated messages have helped maintain pride in what we are doing.
The involvement of clinicians in the assurance process ensures the safety and sustainability of service transfers. The existence of policies and procedures and, more importantly, ensuring that new teams on new sites are familiar with them, is critical.
Use of senior clinical staff from within clinical networks has lent credibility to the process. Recognising that the relocation of services is not the end point, we are working to demonstrate the benefits and ensure the commitments made to staff and public have been achieved.
A programme of change on this scale is not without its challenges. However, with the right clinical and managerial leadership and involvement, a strong shared vision of what we are all trying to achieve and a central programme office supporting dedicated colleagues in the trusts and PCTs, we are making it better for families in Greater Manchester.