Restructuring: united for growth

To call the leader of the UK's first academic health science centre driven would be an understatement. Steve Smith is not prepared to let anything get in the way of his desire to turn his organisation, Imperial College Healthcare trust, into a global top-five academic health science centre by 2012. This would put it on a par with the top 10 hospitals in the world.

Professor Smith has glossy centres of private enterprise such as the Cleveland Clinic and Johns Hopkins Medicine, both in the US, in his sights and believes there is nothing to stop his organisation matching their success in translating cutting-edge research into better patient outcomes.

Currently principal of the faculty of medicine of Imperial College London - ranked fourth in the world for biomedical research - Professor Smith combines this role with that of chief executive of the trust. Imperial College Healthcare trust became the largest in the UK last year after the Hammersmith Hospitals trust and St Mary's trust merged and became integrated with Imperial College. It has five hospitals: Charing Cross, the Hammersmith, Queen Charlotte's and Chelsea, St Mary's Paddington and the Western Eye hospital. The move came after£15m was wasted in trying to develop a robust business case for an attempt to build a facility in London's Paddington Basin to replace St Mary's, Royal Brompton and Harefield hospitals. The Department of Health finally pulled the plug on the development in June 2005.

The academic health science centre got the go-ahead from the health secretary last September and is based on what the trust believes is a unique application of the US concept.

Professor Smith is convinced a groundbreaking process of integration between the university and the NHS will help the trust dissolve artificial barriers between research and healthcare. He wants the trust to be a top-five academic health science centre, as assessed by provision of patient care, patient satisfaction, evidence of innovation, research and income from research, and the centre's ability to attract the most qualified and motivated staff and students.

At the beginning of this month he launched a leadership model that does away with directorates or localities and instead puts clinicians in charge of clinical programme groups. He believes the move will allow the trust to make research breakthroughs faster and get them to patients more quickly.

Working under the board of directors, each of the seven clinical programme groups is to be led by a clinician. Each has a budget of at least£50m a year; some significantly more. Under each of the programme group directors will be heads of finance, education, operations, nursing, research and human resources.

Six of these clinical directors have already been appointed. Each one is "absolutely accountable for everything that happens professionally and financially", says Professor Smith.

The logistics of the merger have been hugely time-consuming. At the time of writing, the programme group directors are still putting their management teams together, which involves managers from the two trusts having to re-apply for their posts.

Approximately 70 per cent of the clinical programme groups' income will come from the NHS, with the balance made up of income from sources including the Medical Research Council, charities and industry.

"The centre is about breaking down the barriers of how we deploy resources, moving away from a monopolistic, monotheist structure to a proper business that has income from a variety of sources that have to be transparently accountable," says Professor Smith.

The unique connection to the university means the organisation has facilities for pooling resources for the benefit of patients, the service, research and education. But there is a limit to the degree of flexibility available.

"I have to legally account for the money to Parliament. I can't take money for education and research and use it for the service and if the trust starts to go bust I can't transfer money from the university to the trust. Neither can the trust take money Parliament has voted for health and use it for other purposes."

The trust can work in a co-ordinated way with its funds, however, as Professor Smith explains: "For example, for gastroenterology we can have a service that's great at delivery, education and research. We now have a process that allows people to plan together rather than trade outcomes."

The trust is focused on substantially improving patient outcomes and satisfaction and is looking at more rigorous measures of patient satisfaction. Although in the context of the UK the two trusts performed well before the merger (healthcare information provider Dr Foster rated Hammersmith Hospitals trust and St Mary's trust as the second and third best hospitals in the country for clinical performance, quality of care and safety), Professor Smith says the hospitals' Picker scores of patient experience have not improved for three years and Britain's position internationally on patient outcomes is poor.

Issues remain around the quality of information the trust has to measure its performance and the quality of its estate. Several sites need to be upgraded significantly.

In order for the trust to gain the most accurate picture of its relative performance globally, it is working with Dr Foster to ensure that, in future, all its standardised mortality measures will be internationally comparable.

Professor Smith cites the trust's West London renal and transplant centre, led by medical director Professor David Taube, as an example of the sort of change in outcomes he wants to see.

"Since integrating research and the service side at the Hammersmith, death rates from transplantation have almost been eliminated and we have increased the number of patients we can take off dialysis," he says. "Neither is it simply a service for Hammersmith patients. All renal services are networked from it."

The centre includes 92 renal beds, an intensive care unit, a high-dependency unit and satellite outpatients services at 11 other hospitals.

Professor Taube says the renal services centre is a precursor that shows how clinical programme groups will fuse research and improved service delivery in other areas. He believes every patient in the trust should be seen by a consultant every day.

"[The renal unit has] six clinical research groups, each headed by a clinical researcher. Each group not only provides clinical research, but decides on the direction of research," he says. The unit has a team led by a chief of service, a general manager and a finance manager.

Mixed response

Professor Taube says service managers who are not clinicians have generally responded positively to the new arrangement. But he continues: "The people who were most threatened were the clinicians, who were worried that this change to the model of care was not what they were used to. Once we get the enthusiasm going and people realise the advantages of determining their own lives, we get huge buy-in to this."

Professors Smith and Taube are passionate about creating networks to spread the benefits of the centre's expertise.

"We have to work very closely with primary care trusts and local hospitals to supply networks of care. We have to work with our local healthcare economy and our commissioners are on-side with this," says Professor Smith.

Jon Restell, chief executive of the union Managers in Partnership, says his members agree that aligning research and education with clinical practice will attract world-class managers as well as clinicians. While new layers of management have been introduced and some people feel a loss of status, "on the plus side there is more of a career structure for managers within the trust and more time available to focus on each area".

He thinks a key point will be how far senior managers will hold clinical programme group directors accountable for performance generally.

Trust operations and performance director Ed Donald says there will be a leadership programme for all managers. "At a personal level it is once in a lifetime that something as innovative and exciting as this comes along and this is a chance to get on the world stage. The place will be run and based on performance and very clear accountability arrangements. It will be a meritocracy."

Grounded in reality

Claire Perry is the newly appointed managing director of Imperial College Healthcare trust. A highly experienced NHS senior manager, she was most recently at University Hospital Lewisham trust, where she held the post of chief executive for six years.

Ms Perry's new role - which the trust believes is the only one of its kind in the UK - was created because of the huge task of bringing together Imperial College and the NHS side, which needs someone to operate at what would usually be the chief executive level.

In this position, she will be required to keep the new organisation grounded in reality. If basics for the service in terms such as government targets and Healthcare Commission standards are not delivered, the trust will not be able to achieve its global objectives.

She says chief executive Professor Smith has "the fantastic vision of making sure every piece of research translates into improvements for patients", while her job is to keep everyone's feet on the ground. "Delivering the basic essentials is the licence to deliver on the whole agenda. We are delivering on all the basics at the moment."

She acknowledges that the eyes of the world are on the fledgling organisation.

"Because we have such huge aspirations, a lot of people are watching us. I am coming from a fantastic baseline of delivery and we must maintain and build on that."

Ms Perry stresses that the trust needs to ensure the complex integrated organisation has the right business processes: "The IT system is going to be absolutely crucial. Our financial systems are crucial. And we need to set ourselves tougher goals still in terms of patient satisfaction and quality of outcomes."

Ms Perry says she was attracted to the job because she believes it is unique in its aspirations.

"There is not another organisation that has the sort of aspirations that are so focused on patient health. I will be leading overall on every aspect of the delivery component.

"I think it is an achievable vision. I have just come from my first morning's work with 60 clinicians and clinical leaders, all of whom were incredibly committed to making it work. We will find a blueprint. People want to make it happen. The danger is that we will lose touch with the basics and that's why I'm so focused on making sure delivery of the basics is ingrained in all of us."

How the programme group for medicine will include experts and involve patients

Dr Gill Gaskin is clinical programme director for medicine at Imperial College Healthcare trust. The largest of the organisation's clinical programme groups, medicine has an annual budget of£100m.

Previously clinical director for medicine at Hammersmith and Charing Cross hospitals since 2002, Dr Gaskin has overseen a wide-ranging programme of innovative changes in the directorate, which have contributed to overall financial and operational performance.

She believes a new leadership model was needed."Service development and outcome improvements were slower than they might be. There was the bureaucracy of dealing with two separate organisations."

Under the new organisation there is a single clinical research office that will bring the research and delivery side together.

"Doing clinical research will be much less painful than ever before," she says.

Dr Gaskin has recruited all but one person to her top team. She has three chiefs of service reporting to her, including a national academic expert as co-ordinator of large-scale studies, a clinical leader experienced at meeting standards in cancer care and an accident and emergency consultant who is the chair of the London emergency medicine consultants' group.

The trick, she says, is to bring experts together: "Integrating them and getting them talking to each other and bouncing ideas off each other and designing all their services."

Dr Gaskin does not want to be held back by any constraints around the national programme for IT, so the trust will add in its own considerable expertise from Imperial College. The trust will also use the Tanaka Business School at Imperial to carry out economic evaluations and evidence-based proposals for change.

Her group will have a high proportion of patients involved in clinical trials and aspires to year-on-year increases in numbers. In terms of being able to measure progress, it is working with Dr Foster to determine what should be measured and how they should do it.

"It means looking at what it does actually mean to be delivering things in certain medical specialties at a world-class level. The ethos and the clinical research methodologies will be the same across the specialties."

The clinical programme groups

• Medicine (including accident and emergency, acute medicine, elderly medicine, infectious disease and infection control).

• Surgery and cancer (including acute surgery, cancer surgery and medical and clinical oncology).

• Specialist services 1 (including anaesthesia and critical care, neurology and neurosurgery, palliative care, plastic and reconstructive surgery and orthopaedic surgery).

• Specialist services 2 (including cardiology, cardiothoracic and thoracic surgery, vascular medicine and renal medicine and transplantation).

• Women's and children's care (including obstetrics, reproductive and antenatal medicine, gynaecology and paediatric medicine, surgery and critical care).

• Clinical and investigative sciences (including imaging and interventional radiology, clinical and laboratory haematology, biochemistry and medicines).

• A seventh group for primary care is being developed. The trust says this will develop public health, epidemiology and primary care.