Test 14 March, 2017

Better care for less

Quality, safety and reliability of services must be our organising principles. Yet delivering reliable services requires us to standardise the evidence of best practice and then organise to deliver this at scale.  This is unlikely to happen whilst we have 238 trusts self-determining their own strategy for their limited catchment area. Inertia prevails when provider interests are put ahead of the interests of the population they should serve. New provider governance arrangements are described in the Dalton Review – such as single shared services, joint ventures, integrated-care organisations and groups/chains. Operating these arrangements at scale (c.1 million plus) allows a single system of governance for strategic decision making and asset management to assure delivery of standards through pooling a service-line workforce across multiple sites.

We have a shortage of high-quality strategic leaders. I strongly advocate the development of groups/chains of providers where each provider in a group takes responsibility for delivering operational excellence and the group takes responsibility for three functions: strategic change, development of standardised systems and pathways and asset renewal. The benefits of scale will not be delivered quickly enough by current trust CEOs trying to reach mutual agreements amongst themselves.

Likewise, CCGs responsibility for commissioning hospital services should be unified rapidly to commission for a c.1 million population and single-service commissions should be given for multiple providers covering a STP population footprint. The number of CCGs should reduce significantly.

Better care and improved outcomes have been delivered from consolidating 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 c.1 million populations with full 24/7 consultant access. Minimising the need for ‘out-of-hours’ surgical and anaesthetic presence at local hospitals will provide economic and outcome benefits.

We need to find a means that allows a capital spend over the next decade to be only 75 per cent or less of the spend over the last decade. This requires us to view the use of our estate differently and drives us to consolidate services into our best conditioned estate and thereby obviate the need for the same level of asset renewal. Again, this is best organised at scale.

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 and enables access to elusive economies. Experienced organisations should be incentivised to manage the roll-out to other organisations.

The cost of labour and use of agency staff is a direct result of the tight labour market, where restrictions in supply have led to cost inflation with staff able to demand higher pay rates. New workforce supply strategies are urgently needed which can provide ease of access to the right skills and quantity of staff.

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 diminished returns. Instead locally selected key performance indicators, focused on the delivery of the NHS Clinical Standards, should be publicly reported on balanced scorecards.

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 to see sustainable change. Linking pay improvement to the contribution individuals and teams make to the goals and values of their employer must be pursued.

This article was first published in Reform’s ‘NHS reform at pace and scale’ conference brochure. To read more articles, click here.