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

Break in the chain

Something seems to have happened in north central London to derail the closer working between the Royal Free and North Middlesex University Hospital.

The latter produced a lengthy document in its most recent board papers outlining the fears of its stakeholders about losing services, identity and local accountability if it joined the Royal Free Group in a more substantive way than it already has.

At the moment the organisations collaborate on standardising some clinical service lines, but a closer union could have involved shared back office and estates functions.

The Royal Free says there was never a formal offer of full membership and NMUH chief executive Maria Kane was at pains to stress how grateful NMUH was for the larger trust’s help on a range of problems.

But the prospect of a full merger, which once seemed possible/likely, seems to have vanished. Royal Free chief executive Sir David Sloman was accountable officer of NMUH for a while and North Middlesex’s previous chief executive was a Royal Free director. Both these things are now not the case.

The Free might say it was never angling for a full merger with NMUH, but that was not how it was seen locally. Healthwatch Enfield’s press release was entitled “Royal Free Will Not Be Taking Over North Mid”, which sounds like something you might read on a placard.

For a while it looked like there was going to be rapid expansion.

Before the Royal Free formally merged with Barnet and Chase Farm Hospitals Trust one of its directors was made acting chief executive.

Another Royal Free director was made interim chief executive of West Hertfordshire Hospitals Trust in 2016, but has now left for a job with a charity.

You could see a pattern developing with the appointment of senior Royal Free staff as interim chief executives and/or accountable officers. But that has come to an end.

At the beginning of the month a joint announcement from the trust and West Herts trumpeted a clinical partnership, but notable by its absence was any move towards deeper integration. Some staff at West Herts had feared a straight-up acquisition by their southern neighbour. That appears to no longer be on the cards.

The news illustrates the different way the four national hospital vanguards have shaped up.

Salford Royal seems to be taking a more direct acquisitive approach with a committee-in-common between it and neighbouring multisite troubled trust Pennine Acute.

Guy’s and St Thomas’ model seems more medically-led and less about back-office efficiencies.

Northumbria’s approach is less clear, but despite a regulatory knockback it still seems to have significant control over North Cumbria University Hospitals Trust.

The direction the Royal Free group will take in the face of this vote of no-confidence from a neighbour remains to be seen.

Talking of the Royal Free…

Another factor could further complicate the group’s future.

There has been quite a lot of talk about who will be the new regional director for London.

A quick reminder, this would be the joint NHS Improvement and NHS England post, one of seven in England. The joint I/E documents said these would be significant roles and London Eye understands the centre would like to attract figures of significant standing from the provider sector.

Many sources have mentioned Sir David Sloman’s name in the running for this position.

The Royal Free boss’s supporters could make a good case for him, if he even wants the job. He has taken a leadership role in north central London, pushing for clinically-led change and trying to integrate with neighbours.

He has led large capital projects (new accident and emergency for the Free and the repurposing of Chase Farm – although this latter admittedly came with a lot of extra central money).

These kinds of multiborough projects are the kind of thing the NHS in London will be hoping to do more of soon. Particularly in north central London where the slow process of moving Moorfields to St Pancras and other services further north could do with speeding up.

On the other hand, although it’s still early days, the Royal Free model has not set the world alight. Others expressed significant misgivings that Sir David would treat London a bit like a strategic health authority. But perhaps these concerns are inevitable when you try and work outside your silo, and do some system leadership.

Whatever happens there is no doubt London misses a health authority that is strategic.

At a King’s Fund event on the five London Sustainability and Transformation Partnerships this week, speakers recognised they had some achievements but noted that overall STPs were “essentially a work-around” and their lack of being-something-that-legally-exists hampered them.

“Bring back Ruth Carnall” said some in the room, noting the former strategic health authority boss’s achievements in stroke and trauma centralisation.

The King’s Fund meeting seemed enthused by this idea of top-down control. But it came after the chair of London clinical commissioniong groups, Sir Sam Everington, made the point that top-down control had infantilised leaders on the ground, who told him “we just have to wait and see who the new regional director is”. Better to have things grow from the ground up, came the opinion, from borough or locality level.

TV presenter Nick Ross, a non-executive director at Imperial, balked at this, pointing out the local authorities housing his unlucky organisation were “biting each other’s faces off” and unwilling to sign-off any move of a service across borough boundaries.

NHS England’s London medical director, Vin Diwaker, who had made a good case for London STPs’ achievements, pointed out that when there had been top-down control people hadn’t liked that either.

I mention all this by way of saying, even if Sir David is offered the job, and he wanted it, would it be do-able? Possibly not.