Sir David Dalton offers an update on what the NHS has achieved in the wake of his inquiry into how to secure the clinical and financial sustainability of care providers through new organisational forms.
It’s been two and a half years since I published my review into options and opportunities for providers of NHS care. It was my privilege to think through and propose, to the health secretary, new ways for providers to address the challenges they faced.
Thirty months later, these challenges of financial and service pressures, and sharp variation in both efficiency and quality, remain. It’s my firm view that the ideas explored in the review still hold true today, and warrant attention from all those providing NHS care. How have we progressed since 2014? And what work still remains?
‘Given recent events, the NHS has shown once again how at times of crisis it can come together in the most admirable of ways’
I started my review by quoting the Care Quality Commission’s 2014 assessment that the “unacceptable variation in quality needs to be widely acknowledged and addressed”. While their 2016 State of Care report admitted this variation largely remains, it encouragingly saw services and leaders as increasingly aware of the need to collaborate and think outside traditional organisational boundaries.
I completely agree; really exciting partnership developments are under way across England: the acute care collaborations; the single shared service concept across multiple organisations; the development of integrated care organisations, and clinical support/corporate service collaborations – with many of these pioneered through NHS England’s new care vanguards programme.
Given recent events, the NHS has shown once again how at times of crisis it can come together in the most admirable of ways. Our challenge is how we can learn to foster such collaboration all of the time, for the ongoing benefit of our patients and populations.
Within my organisation at Salford Royal we are simultaneously involved in all of these new organisational shapes: developing single shared service governance for surgery with partners in Wigan and Bolton, creating shared corporate functions across Greater Manchester, advancing the accountable care organisation concept with partners in the city of Salford and we’re creating a new group of care organisations for a 1.3 million population across the five localities of Salford, Bury, Rochdale, Oldham and North Manchester.
The group concept differs from a traditional merger: the group HQ separates itself from operational delivery, ensuring that each care organisation has senior talented leadership with the authority to decide how to deliver the annual operational plan.
The HQ determines service strategy on behalf of the larger population unimpeded by individual organisational interests which hitherto could impede change; it holds the capital account to get the best value out of estate and equipment; and finally it determines a standard operating model and standard clinical pathways (based on evidence of best practice) which it can deploy across multiple organisations.
The game changer is using digital to enable clinical and managerial decision makers to receive feedback as to the extent to which they are adherent to the standardised approach.
Other innovative collaborations are being seen across the NHS, such as the federation of primary care which is supporting new services which simply wouldn’t be possible if all GP practices acted alone. Furthermore, the coming together of trusts under the shared leadership of some of our most talented leaders, such as Sarah-Jane Marsh in Birmingham, Clare Panniker in Essex, Andrew Cash in Sheffield and David Sloman in London provide further variant options for providers to consider.
We should welcome the diversity and ensure we don’t return to a “one size fits all” approach. Nor should we dismiss ideas just because we think they might not work in our own areas.
While we’ve made advances in terms of better understanding what the different collaborative models are, we’re yet to fully understand how to make these models work. The focus now needs to be on the practical strategies and tactics needed to best make these models deliver improvements for patients and populations.
There’s a range of questions we don’t yet have the answer to – implications for training and development, or how providers decide who best to partner with, being just two. It’s questions such as these a range of us from across the NHS will be exploring at a learning event on 13 June, hosted by Kaleidoscope Health & Care; do join us, tickets are still available.
‘Griffiths’ aim 30 years ago was the same as mine from 30 months ago, and remains today: how we create a sustainable NHS for the long term’
Remembering the well used phrase “form follows function”, we need to ensure that collaborations between providers mean as much to clinicians as they do to managers. No collaboration between healthcare organisations will work if it isn’t underpinned by trusting relationships between individual clinicians. We’re working on this in Salford; it’s also been the particular focus of the partnership between Guy’s and St Thomas’ and Dartford and Gravesham, another of the vanguards.
As with so much NHS change, we mustn’t lose sight of the circularity of the issues we are dealing with. To “involve the clinicians more closely in the management process, consistent with clinical freedom for clinical practice” isn’t a recommendation from my 2014 report, but the 1983 Griffiths inquiry.
Griffiths’ aim 30 years ago was the same as mine from 30 months ago, and remains today: how we create a sustainable NHS for the long term. To do so we need to continue to support our NHS leaders and staff to reduce variation currently experienced and to deliver reliable, high quality care to all.
Sir David Dalton will be speaking at Collaboration: Know-How?, a learning event on provider collaboration, on 13 June in London. Further information is available here.