It’s taking too long to deliver the necessary improvements – here are some thoughts on what we should prioritise
Radical change is needed to tackle variations in standards of care and to secure affordable services. We all praised what the Five Year Forward View wanted us to do but sadly we are behind organising how it can be delivered at pace.
Despite good work on integration and new models of care, it is taking us too long to deliver improvements. Here are some thoughts about priorities:
1. Quality, safety and reliability of services must be our organising principle. Yet no trust is delivering the NHS clinical standards for seven day services. The public should receive a high quality of care wherever they live and yet meeting these standards reliably 24/7 requires a workforce that single organisations cannot provide alone. The organising scale for hospital services should change to serve a population footprint of around one million. Delivering reliable services requires us to standardise to the evidence of best practice and then organise to deliver this at scale. Service change, consolidation and improvement will follow.
2. Decision making takes too long, with 238 trusts determining their strategy for their limited catchment area. Inertia prevails when providers put their own organisational interests ahead of the population they should serve. This ‘power of veto’ should be removed and the role of a provider should be reset to deliver operational excellence to agreed quality standards.
New provider governance arrangements are described in the Dalton Review, eg single-shared services; joint ventures; integrated care organisations and groups/chains. Reducing the number of ‘sovereign’ providers allows quicker strategic decision making, pooling service-line workforce and better use of estate, across multiple providers/sites, to assure delivery of better and affordable care.
3. We should celebrate improved patient outcomes from the consolidation of cancer surgery, trauma and stroke care into regional centres. But the job has only just started: we should quickly consolidate inpatient surgery, especially high risk surgery, into single surgical centres serving populations of around one million. Most inpatient surgery is ‘once in a lifetime’ and should be made available in ‘surgical centres’, with 24/7 consultant availability. Local integrated hospitals should continue to provide assessment, diagnostics, day surgery and relevant local emergency, acute and long term condition management, but should have minimum need for ‘out of hours’ surgical and anaesthetic presence.
4. CCGs’ responsibility for commissioning hospital services should be unified rapidly to commission for a one million population. There should be single contracts or commissions covering multiple providers across a whole sustainability and transformation plan (STP) footprint, across service lines or patient populations. This would mean providers coming together to agree a specification – where appropriate this will enable consent to service change and consolidation. The number of CCGs should reduce significantly.
5. Primary care needs investment and support but it must become part of a single-governed and accountable system. We should organise an accountable primary health and social care system for neighbourhoods of around 50,000 people across the country and we must rapidly complete the journey of full integration of our health and social care systems into accountable care organisations.
6. Inadequate social care funding risks compromising patient care. The outdated funding model should be revised: immediately increased funding should go to the 20 per cent of localities in greatest need; next year funding should be linked to social care transformation and reducing delayed transfers of care; thereafter the ‘triple lock’ on pensions could be loosened and universal allowances could be reconsidered. Alternative, sustainable models should be considered: eg unlocking the accumulated equity in house price growth and encouraging saving/insurance through models which work in other countries eg, Japan, Netherlands and Ireland. Safe and affordable care must be found for our most vulnerable citizens and provided ‘free at the point of need’.
7. Investment in ‘digital’ is a must. Electronic health records not only improve clinical decision making and enable reliable communication with patients but they allow better scheduling and management of patient flow. Digital provides the means to assure standardisation of best practice across multiple providers and enables access to elusive economies. To make it happen, experienced organisations should be incentivised to manage the rollout into other organisations.
8. No other healthcare system has the number of performance targets the English NHS has. The sheer volume distorts real priorities and colossal expenditure is providing diminishing returns. Access targets are now much less important than meeting the agreed seven day NHS Clinical Standards where reliable delivery would provide huge returns for improved safety and outcomes for patients. Current targets should be replaced with locally selected key performance indicators (from a national thematic list) and publicly reported balanced scorecards should be used – where the need for improvement is seen ‘in the round’.
9. Solutions to problems are most likely to be found from listening to and involving staff who will know the impediments which prevent them from providing the safe and reliable care they want for their patients. Their ideas must be encouraged, tested, implemented and spread if we are to see sustainable change. Supporting feedback and coaching to individuals and teams is essential – and linking pay improvement to the contribution individuals and teams make to the goals and values of their employer must be pursued. Staff satisfaction should become a principal metric for assessing a board’s performance.
10. Finally, many staff, whether in primary, community or acute care are showing signs of fatigue and helplessness. Their continued devotion cannot be assumed and their discretionary effort will be withheld unless new workforce supply strategies result in safer staffing levels.
I remain firmly in the optimistic camp. Every day I see amazing care. Yes, it is tough and difficult – but engendering a team spirit in support of our NHS values remains the most rewarding job I can imagine.
Sir David Dalton is chief executive of Salford Royal Foundation Trust and Pennine Acute Hospitals Trust
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