Next stage review: SHAs steer Darzi plans through financial storm

Nine months after the strategic health authorities published their visions of care, as part of Lord Darzi’s next stage review, they are contemplating a new landscape of deep recession and the prospect of funding cuts.

The surprise is not that their implementation plans have been changed but that they can all point to some positive outcomes with more in the pipeline.

HSJ contacted all SHAs involved in last year’s next stage review process to find out how they were progressing with their Darzi visions.

Inevitably, SHAs have had a rethink on some of their targets and the timescale and indicators for implementation.

NHS South East Coast had a monumentally ambitious target of halving teenage pregnancies by 2010. This is now changed to “we will commit to reduce the teenage pregnancy rate” in the SHA’s operating framework, which was signed off last month. Chief executive Candy Morris admits that they risked “getting egg on our faces” with the original target.

In other areas there have been changes to the details: NHS East Midlands is looking at an unknown number of fully integrated stroke centres instead of four specialist centres.

Detailed implementation has also hit some snags: NHS Norfolk wanted to commission 24/7 thrombolysis care from this April, together with other improvements in stroke care, but in January the board was told that costs were greater than originally thought. An office hours scheme has been running at Norfolk and Norwich University Hospital but this won’t be extended to 24 hour coverage until June because of recruitment issues.

And in the North East implementation of four of the eight work streams was behind plan in January - but has now caught up.

Fleshing out the Darzi plans

However, ambitious targets remain: NHS South East Coast is still looking for referral to treatment times to drop to an average of nine weeks this year.

NHS South West is aiming for a maximum wait of eight weeks: figures for January suggest it is well on the way to achieving this; 80 per cent of admitted patients and over 90 per cent of non-admitted patients waited no more than 13 weeks.

Not surprisingly, many SHAs have spent the early months of implementation putting some flesh on the bones of these ideas - and consolidating support for them from NHS bodies and clinicians. Some have also had further public consultation or produced implementation plans.

NHS Yorkshire and the Humber has published an 85-page implementation plan with a more detailed timeline for delivery. It has also put considerable time into planning how organisations will be judged in the delivery of a set of performance matrices, looking at key indicators.

PCTs will set trajectories showing how they plan to perform on these over time and will be monitored by the SHA, which is looking for stretching but achievable targets.

NHS South East Coast has embedded its targets into its own operating framework. Commissioning for quality and innovation (CQUIN) is also being used to incentivise change in some areas.

NHS South Central is reorganising itself around the clinical pathways outlined in its report and has recruited clinical directors for each of them, including some from a non-medical background. Director of clinical standards Katherine Fenton says this is why the SHA might have been slower than others in making long term decisions.

Much of this early work by SHAs is likely to be around planning, carrying out baseline assessments and agreeing specifications.

This is necessary but unlikely to grab the headlines or persuade the public that the NHS has really transformed.

But some early deliverables will be noticed by patients. NHS South West says its monitoring suggests that mothers-to-be will have a choice of at least three places to give birth by the end of this month - in line with its target of being ahead of the national delivery of the Maternity Matters strategy. More money is going into end of life care on the Isle of Wight.

And although progress on stroke care in the East of England has not been as fast as PCTs would have liked, an awful lot more people can now access thrombolysis swiftly. Medical director Robert Winter says these early wins can help persuade people that it is worth remaining engaged with other parts of the programme which deliver over a longer timeframe and may have less easily measurable results.

In the South East new pathways have been agreed with the ambulance service so patients are taken to the most appropriate hospital.

Candy Morris says a pensioner taken ill on a ferry with a suspected stroke just before Christmas was met by an ambulance at Dover, taken straight to the Kent and Canterbury Hospital for thromobolysis and has made a full recovery.

Public health is also prominent, especially in areas like the North East, which has generally good services but poor health. Multi-agency approaches to issues such as smoking and alcohol misuse have already led to service changes.

Local health priorities

But there is often a need for local rather than SHA priorities to be reflected in delivery.

Allowing some local determination of how plans are pushed forward is seen as important: in the West Midlands centralised and non-centralised models for stroke thrombolysis have emerged, reflecting differences within the region and decisions made by PCTs.

Keeping clinical engagement going is key: many SHAs feel clinicians are enthused by a vision based on quality rather than structure.

Ms Fenton describes clinicians as “hungry” and says there was a good field of quality candidates for the clinical directors jobs.

NHS West Midlands has appointed 13 clinicians to drive forward work. Other areas have gone for up to 120 clinical champions. In most cases, clinicians are getting protected time for this work.

Costs are also coming to the fore. While no one admits that the financial downturn is putting pressure on plans, there is an increased emphasis on cost effectiveness and the generation of further savings from investment in quality care.

“This is the time when quality and innovation can actually drive improvements in service and reductions in cost,” says Ms Morris. The current financial environment provides a “catalyst” for moving forward as fast as possible, she says.

However, it is likely some of the improvements will shift costs forward, offering savings on long term care and also social care and other areas outside the NHS budget.

And in some areas the evidence base for cost savings is less secure and it may be harder to demonstrate the invest-to-save argument.

The other side of the coin is the need to disinvest from areas where there is no evidence of positive outcomes: NHS West Midlands had flagged this up in its document but has not really got to grips with disinvestment yet.

Most SHAs feel they have made a promising start to the implementation process, but with an election looming there may be pressure to deliver more changes on the ground.

The pace of change is such that there probably will be things to boast about - the availability of primary angioplasty for heart attacks and thrombolysis for stroke is about to increase exponentially.

But there will also be unpopular decisions to be made. In some areas, centralising services at centres of excellence could affect numbers seen at local accident and emergency departments and the NHS may have to counter perceptions that they are being downgraded.

Maternity is another difficult issue: many SHAs are committed to 60 or more hours of consultant cover at maternity units but this could impact on the number of units which are viable as a “full” consultant led service. Inpatient children’s services could also be tricky to handle.

Some SHAs committed from the start to maintaining existing A&E and maternity services at all current sites. East of England is hoping to make more use of managed clinical networks to provide quality services at all sites. “That was a big plus point,” says Robert Winter. “Trusts saw it as a way in which their units could look to a secure future.” Others have gone through painful reconfigurations and already have what looks like viable units.

But others will ultimately have to go out to public consultation on changes. Privately, some managers say the time needed to draw up plans - and have a discussion with the public about what constitutes quality care - may already be pushing this beyond the election.

The next stage review has delivered some successes some far, and there are more in the pipeline. But support from clinicians and public has yet to be tested by unpopular decisions.