Hospital bed

Starting with hospital reform will make things worse

By: Ben Gowland CEO NHS Nene Clinical Commissioning Group @ccginsider
Published: Monday, January 19, 2015 - 01:58 GMT Jump to Comments

Efforts to transform the NHS will fail if we heed the Dalton Review and put all our effort into changing hospitals, instead of focussing on the needs of the whole system

The Dalton Review, published just before Christmas and tinkered with in January has developed a set of proposals that will reform the hospital landscape within the NHS.  The new models include ‘multi-service chains’, where you would have chains of (for example) Guy’s and St Thomas’ Hospitals up and down the country, and ‘service-level chains’ where you would have single specialties such as cancer services delivered by one provider within other organisations, for example Christie Cancer Services in Barnsley or Christie Cancer Services in Watford.

As well as outlining the different organisational forms, the report explains how successful organisations can take over failing organisations to make them successful as well.  The way this is going to work is that there will be a ‘credentialing’ process, whereby those capable of spreading their success will be authorised to do so.  They will gain a kite mark which will mean we can all be confident that those taking over other organisations will do so successfully.

Credentialing aside, the main problem with the report is that it is only talking about the future of hospitals.  The majority of options are only really open to hospitals.  Even the description of an Integrated Care Organisation as a potential model places hospitals firmly at the centre.  Meanwhile the startling omission from the document is that it does not even mention general practice. 

This means we have the 5 Year Forward View that describes new organisations built around general practice, while this report only describes new organisational forms for hospitals without presenting any explanation or apology for this dissonance.  Any neutral observer of the NHS would say that the biggest provider development need in the NHS today is in general practice. There are over 8,000 GP practices in the NHS run in the main as small, independent businesses, who in the face of an overwhelming recruitment crisis and soaring demand, are desperately trying to consolidate.  If the 5 year forward view is going to deliver, this is where the immediate focus of provider development needs to be.

The starting point for this review should have been how we transform the system, in the way outlined in the 5 Year Forward View.  But instead it is premised on making existing hospital providers sustainable.  Provider reform should not be an end in itself, but rather an enabler for system reform.  The token references to the five year forward view in this report are lost in the recommendations for immediate action and milestones and trajectories, that all look like a mini-industry waiting to happen.

There is no track record of hospital reform making things better.  A 2012 article in the Journal of Health Economics entitled ‘Can governments do it better? Merger mania and hospital outcomes in the English NHS’ showed that there were no productivity improvements in 102 out of 112 acute hospital mergers between 1997 and 2006, and that there was also some evidence of reductions in quality as a result of mergers.   As Candace Imison concluded in her introduction to the King’s Fund publication, ‘Future Organisational Models for the NHS’, the higher the degree of organisational change, the higher the risk that the benefits will not be delivered.  So if we want to deliver system reform in the next five years, wholesale organisational change of hospitals is not the place to start.

There is no doubt that hospitals need to change.  But the priority for the NHS must be to change the way our systems operate that will enable us to build care around the needs of patients, rather than around the organisations within it.  This report unfortunately misses this point, and sadly as a result is likely to focus efforts in a way that will hinder rather than help the delivery of real improvement in the NHS.

Ben Gowland and Joe Tibbetts discuss the Dalton Review in their weekly podcast RealityBites - The National Health and Care Conversation published in the Information Daily Tuesday 20th January

The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of The Information Daily, its parent company or any associated businesses.

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