Probe into poor accident and emergency services in north west London has been commissioned by four London local authorities, plus the rest of today’s health news and comment

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5.15pm The Architects’ Journal reports that a judicial review into the location of a proposed cancer centre at Barts Health Trust has been dropped after amendments were made to the design of the building.

Sir Marcus Setchell, previously a consultant at Barts, had threatened to launch a legal challenge against the plans because he said it would negatively impact on the eighteenth century Great Hall on the site.

5.05pm NHS Clinical Commissioners has responded to the Dalton review.

Director Julie Wood said: “The Dalton Report is a vital part of the process to move the NHS to a more secure and sustainable place and the recommendations clearly sit alongside the Five Year Forward View ambitions. NHSCC welcomes the assertion that one size does not fit all and the overarching theme of the report to allow local health systems to work together to find the right local solutions for their patients and populations. Utilising all the funds that are available across whole local health systems, including any accumulated cash surpluses held by Trusts will be critical.“

“Sir David’s recommendation that national bodies and the wider system needs to accelerate its approach to transformation and change will be welcomed by our members - CCGs are already working hard to innovate and deliver new models of care so to have the whole system working at the same pace will ensure that patients benefit.”

3.50pm The King’s Fund has updated its tracker looking at where each political party stands on health in the run-up to the election.

3.35pm The CQC has provided some more detail on the errors in its intelligent monitoring for GP practices.

3.25pm Here’s an interesting reader comment on our story about NEW Devon CCGs restricting access to surgery for obese patients and smokers:

“Has the CCG considered the potential for legal challenge to this approach? The CCG is implementing this as a temporary measure to help it manage demand and cost; were this to be implemented on a permanent basis as a result of a clinical rationale that would be quite a different matter. Essentially, they can’t afford to pay for the treatment that patients need so they have decided on that basis to restrict access to care. I would suggest that the CCG has a look at its own obligations and in particular the rationale they applied and what decision making process was undertaken, because as sure as night turns to day they will end up being challenged probably via a JR.”

2.35pm Here are some reader comments in response to our story on the Dalton review:

“A very helpful set of recommendations for the leadership challenge of having safe, high quality clinical services run by sustainable organisations. In general we need the national bodies to listen to the service’s plea for more simple, streamlined, faster processes to enact transformation and change - we all know what needs doing, let’s get on and do it!”

“Probably makes some sense but really plays into the hands of the private sector in a big way as most NHS organisations are fully occupied on bilge pumps and preparing lifeboats…”

2.15pm The Royal College of Surgeons has responded to NEW Devon CCGs’ plans to restrict access to surgery for obese patients and smokers.

A spokesperson said: “We remain concerned that NEW Devon CCG are rationing access to scheduled surgery solely as a way to manage financial pressures. By delaying operations using short-term measures this will store up greater pressures on the service in the future.

“The need for an operation should always be judged by a surgeon based on their clinical assessment of the patient and the risks and benefits of the surgery - not determined by arbitrary criteria. Losing weight, or giving up smoking is an important consideration for patients undergoing surgery in order to improve their outcomes but for some patients these steps may not be possible. A blanket ban on scheduled operations for those who cannot follow these measures is unacceptable and too rigid a measure for ensuring patients receive the best care possible.

“The Royal College of Surgeons has worked hard to produce clear guidance, accredited by the expert body NICE to support those commissioning or buying surgery.”

2.10pm On Monday HSJ will host its inaugral annual lecture.

HSJ editor Alastair McLellan has just tweeted: “Simon Stevens tells the audience he will Simon Stevens tells #HFMA conf he will set out likely ‘strategic direction’ of NHS at Monday’s 1st HSJ Lecture

The mission of King’s Health Partners is to transform healthcare locally and globally – both in south London where the organisation is based, and in the developing world. 

One of its members, King’s College Hospital, began working with Somaliland 13 years ago with charity the Tropical Health and Education Trust to support the development of medical and nursing schools.

1.40pm Jeremy Hunt has made a written statement on the Dalton review, in which he writes that the government “welcomes the Review and its recommendations, encourages all those working in or with the NHS to consider the options and recommendations of the Review and will take a close interest in their adoption and implementation over the coming months”.

1.15pm NHS Providers, formerly Foundation Trust Network, has welcomed the Dalton review into new provider models.

Chief executive Chris Hopson said: “Sir David Dalton’s report provides a welcome review led from within the sector of how different organisational forms can act as an enabler to help NHS providers secure the clinical and financial sustainability of care in the future. We have been pleased to contribute to the expert advisory panel which informed the review, alongside a number of chief executives from across our membership, and to share existing learning and perspectives from our members.  We look forward to working with the NHS Confederation to share the learning from the review in coming months.

“The report is right to argue that the NHS has to adapt to meet 21st century patient needs. As increasing numbers of providers may plan transactions to improve quality standards or in response to changes in the financial climate, the emphasis the review places on the need to streamline the transactions process is particularly welcome, as is a focus on ensuring progress through the FT pipeline and securing a sustainable futures for NHS providers.

“This report complements the new models of care set out in the Five Year Forward View, and the emphasis on a ‘no one size fits all’ approach led locally and collaboratively by NHS providers in partnership with commissioners and partners in the local health economy is equally helpful. However, it’s essential that the regulatory and policy frameworks are flexible enough to enable NHS providers to develop the organisational structures which support new and more integrated models of care with the twin pillars of the FT concept – provider autonomy and local accountability – at the heart of this process. 

“While organisational form can be one important catalyst for change, as the report acknowledges it is never an end in itself. Any new models of care must be robustly governed with due local accountability, and put patient needs first in acute, community, mental health and ambulance settings. The NHS provider sector must also receive a fair funding settlement and proportionate, risk based regulation if we are to be in a position to take full advantage of the options and opportunities that flexing organisational form may offer.” 

1.10pm The BBC reports that around 350, or 5 per cent of all GP surgeries, could be rebanded into different risk ratings after the CQC made errors in its calculations.

1.05pm BBC health editor Hugh Pym has just tweeted: “BBC exclusive : CQC rebrands risk ratings of hundreds of GP surgeries inc moving 60 from high to lower risk”

1.00pm The Health Foundation has responded to the Dalton review.

Chief executive Jennifer Dixon said: “The Dalton Review has one central message: give better performing trusts a bigger role in helping those performing less well and also in accelerating plans for new models of care, as outlined in the recent NHS Five Year Forward View.

“That message is right. It is welcome that trusts who are performing well provide support for those that are not, whether through a peer to peer buddying role or more formal acquisition if appropriate. It may help the spread of good operational management, which must be central to good performance. Dalton’s suggestion is a sensible addition to the current ‘top-down’ approach when organisations are failing.

“But two caveats. First the key lies in how strong performers are identified or ‘credentialled’. As Care Quality Commission (CQC) reports show, a trust performing well overall on current metrics is not likely to be performing well in every area. Also, it may not necessarily be skilled in the large-scale change needed to achieve new models of care. On the other hand, a poor performer may be well managed, but struggling because of a range of external factors such as weak primary care, patchy social care, historic funding under the needs based resource allocation target, or failure in a neighbouring trust leading to excessive demand on emergency care. These may be factors that a well performing trust has not had to face or are out of their control.

“Second, buddying may be a stretch too far for trusts that are performing well, and lead to a dip (temporary or longer) in performance. The evidence on the impact of mergers, for example, is not very positive. Implementing Dalton’s suggestions will need very close monitoring, particularly in areas of quality not included on the usual dashboards.

“Turning around performance needs skill, whether from within or without. Dalton rightly focuses on the need to build skills in management and leadership, helped by the NHS Leadership Academy. But quality improvement skills in frontline clinicians and managers  are equally critical, as Dalton knows from Salford Royal, where he is Chief Executive. How best to develop these skills across England, at pace, is now a very critical question for the NHS.”

John Wicks will join the North West CCG, which was probed by NHS England earlier this year in relation to serious concerns about its leadership.

The CCG chair and accountable officer “stepped away” from their duties to make way for the review, which concluded in September that the group’s structures were “not fit for purpose”.

12.30pm As part of the Dalton review the Nuffield Trust was asked to look at what lessons could be learned from other sectors.

They concluded that multi-site chains will need to work differently from merged organisations in the past. Rather than one organisation taking over another and running it using its existing management, there needs to be a separate corporate core that oversees the different sites, they say.

Patients living in the area covered by Northern, Eastern and Western Devon CCG will also have to show they have stopped smoking for eight weeks before they can undergo routine procedures.

These stringent access policies for routine surgery - announced this week - are in addition to restrictions announced on hip and knee replacements for obese patients and smokers which have already been introduced.

12.00pm The Parliamentary and Health Service Ombudsman has upheld more complaints than in previous years.

So far this year, the Ombudsman Service has completed 2,532 investigations about the NHS in England and UK government departments and their agencies. It upheld complaints in 960 of these investigations. In the same period last year (April to November 2013) it completed 867 investigations and upheld 344 cases.

Parliamentary and Health Service Ombudsman Julie Mellor said: “We have made important changes to our service including giving more people justice by doing thousands of investigations every year and halving the average time it takes to complete a case, whilst maintaining satisfaction with our service and decisions.

“We are on a journey and will continue to listen and be open and transparent about the changes we are making.”

The government commissioned Dalton review, published this morning, outlines a series of organisational forms that “have the potential for wider adoption across NHS providers”.

These include hospital chains, Hinchingbrooke style management franchises, Moorfields style service level chains, federations, joint ventures and integrated care organisations.

The councils - all Labour led - have appointed Michael Mansfield QC to lead the probe. He was the high profile lawyer who chaired an inquiry into the planned downgrade of Lewisham Hospital’s A&E - a proposal that was quashed last year by a judicial review.

While no budget appears to have been set, the inquiry has been commissioned by Hammersmith and Fulham, Brent, Hounslow, and Ealing councils.

11.10am There has been an increase in data breaches in the healthcare sector as a result of human error, according to encryption services provider Egress Software Technologies.

Through freedom of information requests the company found there were 734 data loss incidents between April 2013 and June of this year.

The FOI found that:

  • Healthcare organisations top the list of most data breaches with 183 in 2014, a 101 per cent increase from 2013
  • Quarter of reported data breaches were caused by the accidental loss or destruction of personal data
  • One incident involved patient data discovered in waste bins and black plastic bags and another reported incident found that the disposal of hard drives containing patient data was insecurely discarded, breaching several protocols.

11.05am HSJ’s campaign calling for respect for NHS managers has reached 64,000 people.

Please keep sharing the open letter signed by sector leaders.

11.00am Emergency admissions via accident and emergency departments were at their highest ever recorded level last week, according to the latest figures from NHS England.

The figures show that 80,131 patients were admitted through A&E, the highest number since 2011.

This continuing demand is reflected in the four hour target performance, with only 90.4 per cent of patients seen within four hours.

10.55am Part of the review’s conclusion is that the “extent of variation of standards across the country” and the “challenges” providers face “must be addressed as soon as possible”.

10.50am The review says that Monitor should consider using its existing categorisation process to drive “more rapid interventions”.

It it determines that an FT is in “persistent difficulty” it should require the FT to produce a plan with improvement timescales. If the FT cannot demonstrate any improvement then Monitor should require a “sustainability plan”, which may include taking on a new organisational form or partnering with a credentialed organisation.

10.30am The buddying system should be expanded, beyond special measures trusts, into a partnering system to give organisations with the potential to improve early access to support and guidance from “credentialed’ organisations.

Trusts that can provide support should be remunerated for their work.

“Should buddying not result in the required improvement within a defined time period, a re-categorisation of the NHS body should be considered so that further action can be enacted quickly.”


10.21am The review also calls for a a “credentialing” process for providers who have successful systems that could be replicated at other organisations.

This should be developed by July 2015 and should build on CQC and Monitor ratings, with a ‘good’ or ‘outstanding’ rating a prerequisite.

Monitor should be responsible for this process and the first wave of credentialing should be completed by October 2015.

CCGs and providers should use this list of credentialed organisations to find new partner organisations that are most likely to deliver transformational improvement.

10.20am Here’s a recommendation for CCGs:

NHS England should require Clinical Commissioning Groups (CCGs) to set out in their five year strategic commissioning plans:

a. the future care/service models they wish to support; and,

b. how they will use their allocated funds for service transformation to support providers to deliver the agreed transformational and organisational change.

Where multiple CCGs and providers are taking forward service transformation across a shared geographical area, NHS England should help brokeragreement as to how costs are met between all parties.

10.17am Dalton is calling for new models to be adopted quickly. He has recommendad that the Secretary of State should set a requirement to the national bodies that, except in exceptional circumstances, all transactions should be completed within one year or less from the time the decision is taken by the board of the TDA or Monitor.

10.15am Chief executive of NHS Confederation, Rob Webster, who was a member of the expert panel informing the Dalton Review has responded to its publication:

He said: “This is a landmark report for the NHS and for providers of NHS care. I am proud to have been part of the Expert Panel that supported the report and look forward to supporting its implementation through the NHS Confederation.

“At its heart, this review is about two simple things. Firstly, that we must tackle variations in quality of care that we provide. And secondly, that there are no right or wrong organisational form, what matters is what works.

“Many members - from all sectors of commissioning and all types of provision - will read the report and be supportive of the permissive approach being taken. I have heard much in the last few months of how provider members are working to understand how they remain sustainable into the next 5 years. They are working across mental health, acute, community and GP boundaries. They are collaborating as independent, NHS and voluntary sector organisations too.

“This report - building on the signals within the Five Year Forward View - has many of the answers that providers and commissioners will consider as they seek to decide on the right organisational form for their services in their economy for their patients. 

“Members from all sectors will particularly welcome the approach to speeding up change and supporting demonstrator sites. We look forward to the response from the Department of Health and arms-length bodies with interest.”

David Hare, chief executive of the NHS Partners Network, said: “The NHS Partners Network strongly welcomes Sir David Dalton’s considered and pragmatic report on new options and opportunities for providers of NHS care. As Sir David makes clear the NHS provider sector is highly varied and includes publicly-owned, independent, voluntary and social enterprise providers. This rich mix of provision has served patients well for many years but there is now a real opportunity to think creatively about new organisational forms drawing on the skills and experience of a range of different providers.

“As Sir David identifies, opportunities for greater partnership working with independent and voluntary sector organisations must be more widely utilised by all types of provider, with scope for a set of different arrangements depending upon need. Alongside the NHS Five Year Forward View this report offers a very clear roadmap for the development of new models of care to meet the needs of patients in a variety of settings.

“It is now important that providers are given permission to test these new ways of working and that all options are on the table for sustaining a 21st century health service free at the point of use.”

10.10am Here’s a recommendation for Monitor and the TDA:

A procurement framework should be developed which allows interested credentialed organisations the ability to register for management contract and acquisition opportunities. This framework should be live from or before April 2016.

Inclusion on this register would mean that an organisation automatically passes the prequalification questionnaire (PQQ) stage of any tendering processes. The framework should then be used by the TDA and Monitor to procure support for challenged organisations.

10.08am There is a particularly interesting recommendation on struggling providers who cannot become FTs:

The TDA should consider accelerating the solutions for patients and communities currently served by organisations in persistent difficulty, by running batched procurements for category B1 and B2 NHS Trusts.

Category B1 are described as organisations that cannot reach FT status in their current form and where an acquisition by another organisation is likely to be the best route to sustainability.

Category B2 are described as organisations that cannot reach FT status on their own and where a franchise, management contract or other innovative organisational form is likely to be the best route to sustainability

10.07am Another recommendation:

Where Monitor determines that a FT is in ‘persistent difficulty’, it should require that FT to produce a plan with clear improvement timescales. If the FT is subsequently unable to demonstrate improvement against this plan, Monitor should compel that FT to present a new sustainability plan. This may include adopting a new organisational form or pursuing a transaction with a ‘credentialed’ organisation.

10.05am Here’s an interesting recommendation from the Dalton review:

The Department of Health, Monitor and the CQC should agree a ‘grace period’ forvacquiring organisation with an agreed trajectory of finance, performance and quality standards improvement for the acquired or contractually managed organisation, separate from the overall performance of the combined organisations.

This ‘grace period’ should take into account historical quality issues and the impact of any agreed financial investment adjustments.

9.45am David Dalton’s review into options and opportunities for providers has been published this morning.

We will be providing full coverage shortly, but here are some of the key points.

  • One size does not fit all

New providers forms should suit local circumstances, without being centrally dictated. The report states: “Too often organisations seek to retain the status quo at the expense of operating outside of traditional organisational boundaries and fail to adopt best practice or pursue wider system leadership which could deliver improvements for patients”.

7.00am Good morning and welcome to HSJ Live. We begin the day with an opinion piece on obesity from Henning Bliddal, head of the Parker Institute in Copenhagen.

Around 60,000 British patients face the trauma of knee surgery each year, and the obesity epidemic is compounding the problem.

However for obese patients with osteoarthritis in their knees, surgery often leads to further weight gain.

Henning argues that changing behaviour and reducing body weight can work wonders and save the NHS money.