Saffron Cordery on the three key aspects in reforming local health economies: how we reorganise and consolidate; which economies of scale are right; and what we are trying to achieve through integration

These days there’s much talk of consolidation and realignment across the NHS. Perhaps there’s something in the water. The provider landscape is changing.

We’ve got the national bodies reconfiguring, new regions with significantly more devolved power, clinical commissioning groups scaling up, GP federations and primary care networks coming more centre stage, integrated care systems and sustainability and transformation partnerships supporting integration, and sustained interest in trust mergers, new collaborative models and groups.

There’s nothing wrong with all this. It’s part of the “natural” ebb and flow of a system in flux. And, with the right local leadership and careful planning, it will lead to better care and patient outcomes.

Frontline services and organisations

However, we do need to make sure that, in amongst all this change, we don’t lose sight of the contribution of established frontline services and organisations doing a good job in difficult circumstances. And we need to be clear who actually drives the reconfiguration – is it local or is it national? In a recent column, Lawrence Dunhill touched on these questions when he argued that:

“The most obvious candidates for consolidation would be the small widely-spread providers which don’t fit comfortably into the emerging integrated care models…the writing has basically been on the wall for standalone community trusts since the Kirkup report into serious quality and governance failings at Liverpool Community Health Trust.”

We mustn’t throw the successful local service baby out with the provider sector consolidation bath water

This seems to suggest that a single solution should be applied – no more standalone community trusts and small and widespread providers aren’t sustainable – and the provider landscape should be shaped from above according to national prescriptions such as these. But there are very different, valid, perspectives here.

While there may be some small standalone community trusts that find themselves unsustainable, a roll call of the success of the majority of the 21 standalone community trusts up and down the country shows they can combine the spirit of integration writ large with a very personal level of service.

Cambridgeshire Community Services Trust has embedded its services firmly into its community. It combines contraception and sexual health services into a single excellent service that meets the needs of local people across a wide geographic footprint, with a particular focus on those not readily accessing services. They’ve innovated and deliver standardised, cost effective, high quality services: one stop shops and quick and easy remote testing.

Sussex Community Foundation Trust runs a Hospital@Home service with Brighton and Sussex University Hospital. Community nurses and therapists look after patients with complex needs at home. Patient feedback is positive and the scheme is popular with staff. The cost of patients cared for by Hospital@Home is 27 per cent less than if they were looked after in an acute setting over the same period.

These examples, surely, are the very essence of what the long-term plan wants to do.

So, we need to be careful about making assumptions that certain types of organisational form no longer fit the bill and that all we need is blanket application of national prescriptions. Instead, let’s have a grown up, evidence based, debate on the three main issues in the context of what works for each locality: how we reorganise and consolidate; what economies of scale are right; and what we are trying to achieve through integration.

So, first, how do we make the decisions about where reorganisation and consolidation are needed? Local providers, commissioners, patients and partners are, surely, best placed to determine the pattern of local services. If our national system leaders think an existing configuration is unsustainable, they should be challenging the local system to devise a new pattern, not trying to redesign the map themselves. They will need to enable and support and, on occasions, referee and intervene. But we should be really wary of the current suggestions and talk that NHS England/Improvement should have the power to mandate a provider trust to merge.

Second, there is an obsession with size. But is big always best? We need a diversity of views here. There’s an inexorable drift towards trust mergers and group models, usually to dig one or more provider organisations out of a financial or quality performance hole, but is this always right or sustainable? What we’re lacking at the moment is an evidence base to show what does, or doesn’t work, and an understanding, nationally, that what works in one place is not always the solution in another.

There’s a desire from the centre to “scale up” but, in some places, “widening out” or even “scaling down” may be the right answer.

Third, we need to take a long hard look at what we’re trying to achieve with consolidation and integration and be creative. They come in all sorts of shapes and sizes – we need to let local systems pick the approach that best suits them. Vertical integration is one route – tried and tested through a number of different vanguard new care models. But there are other forms of geometry too – integrating back office and other services across a number of organisations; sharing an organisational chair to reinforce links and partnerships; or forming committees in common to guide decision making.

We can approach change in many different ways – but one thing is clear – we mustn’t throw the successful local service baby out with the provider sector consolidation bath water.