The NHS in Lewisham: a victory for natural justice?

Vox PopuliLewisham Healthcare NHS Trust is a mid-sized organisation (turnover in 2010/11 was about £220m) that includes acute hospital and local community services.  It produced a surplus of about £1m in that year, having overcome recurrent deficits to achieve sustained surpluses over a relatively short time http://tinyurl.com/p9yvq93. It epitomizes the successful integrated NHS organization: financially stable, well liked by its users, and expecting to achieve Foundation Trust status until external events overtook it.

Its misfortune was to be sited close to the vast, failing South London Trust, which was put into administration in July 2012, with losses predicted to exceed £60m annually. In early 2013, the Secretary of State for Health Jeremy Hunt agreed with the administrator (Matthew Kershaw, from McKinsey) that the Lewisham Trust should merge with part of the dissolved South London Trust, with the downgrading of its University Hospital and the closure of its A&E Department http://tinyurl.com/oqn57lu.

This decision was challenged legally, and a judgement has overturned it http://tinyurl.com/pn27366 , although the Government is considering an appeal.

The judgment is important, not only for the Trust, but for the messages it sends out about the NHS, its drivers, controls, and self determination. There are at least three main points:

1  Externally driven NHS Trusts may as well be directly managed units

Over the past few years, the Lewisham Trust has shown the value and impact of self determination.  It successfully overcame its financial problems, absorbed community services, and built up a reputation as a thriving, effective organization, a significant ‘player’ in its local health economy. If these achievements are discounted, and its future determined by Whitehall, then staff (clinical and otherwise), users, and local organisations such as the Council, will all see themselves as entirely disenfranchised; how that perception is incorporated into a political agenda of ‘localism’ poses an interesting challenge.

2  Expectations raised and dashed are worse than no expectations at all

The current NHS reforms in England are based on a few simple foundations. The first acknowledges clinicians’ impact on the processes and outcomes of health care by involving them in driving these; doing so produces a degree of ‘buy in’ and responsibility amongst clinicians, and develops a new and appropriate line of clinical accountability. The second is an extension of this: as general practitioners instigate most NHS spending through their prescribing and their referrals, they should be involved in the strategic spending decisions as well as the operational ones. This allows more rational and coherent planning, with the ‘ownership’ needed for responsible, accountable working.

The Clinical Commissioning Groups (CCGs) currently finding their feet are the organisational embodiment of these simple foundations, with responsibility for around two thirds of the entire NHS budget of £108 billion, and some influence over the rest. The key tasks they face in their first year are not only to learn to walk (by getting themselves established, and their members engaged), but also to run (by producing considerable savings, and starting to plan their future, more strategic activities).

These tasks would be hard enough, but if the application of their new found skills were to be immediately overturned by Governmental dictat, then all the efforts that have been applied in overcoming GPs’ natural cynicism about involvement in commissioning will have been wasted; the noise of the ensuing disenchantment is likely to drown out for many years any attempts to achieve the same aims.

3  ‘Vox populi’ is not democracy

If the lay press is to be believed http://tinyurl.com/qx2xvve , the recent judgement seems to have been driven entirely by local activists trying to save their hospital. Whilst local support is helpful, it would be bad for any part of the welfare state if national policy was only the result of local pressure.

The NHS was designed to be both egalitarian and utilitarian, and as such, ‘broad brush’ strategy needs to be driven in a systematic, rigorous fashion. The recent Health and Social Care Act http://tinyurl.com/pj3j4v3 suggests that decisions about service configuration should be made by CCGs working together, with appropriate input from NHS England, under the aegis of overarching Government policy. Whilst patients and the public are obviously important protagonists, it would be a dangerous precedent if major reconfigurations were seen to be driven by public demonstrations.

Finally, it is worth considering how the reconfiguration exercise might have been handled better. Once the South London Trust had been disbanded, it should have been the CCGs working with NHS England who made the strategic ‘macro’ decisions about the overall shape of service delivery; the operational details, the ‘micro’ decisions, should (in theory at least) been left to the new delivery organisations to define themselves, in response to an outline brief (‘what is required’) rather than any overprescriptive, micromanaged approach (‘this is how we want you to do it’). Broad brush strategic management needs the high level players to be involved, but preferably not the politicians; operational delivery is best left to those who know how to do it.

This piece is based on an article published in The Conversation on 1 August 2013, which can be read at http://tinyurl.com/p6wom8j

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A&E departments and the M25 effect

I’ve just done a shorImaget slot on the local radio, talking about the ‘crisis in A&E’. It was based on the new report by the Health Select Committee that highlights the issues, but says very little that is new about their solution. We know that A&E is the ‘safety valve’ for the system, we know that the patients are confused about its role, and we know that fewer and fewer doctors choose to work there.

However, the solutions mentioned by the Committee are almost entirely structural and unimaginative: beefing up the Urgent Care Boards from small talking shops into larger talking shops really isn’t the answer; neither is a vague exhortation that Ambulance Trusts should become ‘care providers in their own right’.

Perhaps it would be helpful to reframe the issues, and consider them in a slightly different way. If we look at A&E from the perspectives of hospitals providers, of those working in the community, and of patients themselves, we might get a more rounded view of the problems and maybe their solutions.

Hospitals are under tremendous pressure; they have to see patients referred to them within eighteen weeks, admit acutely ill patients from Casualty in under four hours, and do it all within ever tighter financial and quality constraints. To deal with the front door issues posed by A&E, they have introduced more and more services there, so that for many patients, turning up at the emergency department offers a ‘one stop shop’ solution to their problems. The paradox is that the more that is provided at A&E, the more the service will be used.

Clearly, the corollary of reducing services at the front door is probably not a viable option in political or practical terms, but at least we should be aware of the dynamics of supply and demand in this setting, and think twice before we get seduced by more manifestations of the M25 effect.

From a community services perspective, it’s worth asking what the incentives and disincentives are to sending people to A&E: in the middle of the night, at an ill patient’s bedside, when relatives are panicking, no other care facilities are available, and the hospital light is on (to use Stephen Dorrell’s image), why shouldn’t the ‘on call’ clinician send the patient into hospital?

The presence in NHS111 of a telehealth service that seems to do no more than signpost the road to A&E doesn’t really help either; one of the reasons we have trained professionals is to cope with risk and uncertainty in a way that an algorithmic system simply cannot do, and offering a cut price alternative was predicted by everyone but the party politicians not to work.

From the poor benighted patients’ point of view, they are faced with the emotive issues of ill health, with little or no information, often on their own, fed by a media diet of Holby City on the telly, and instant gratification in all other aspects of their lives; they also know that if they call their GP they will have a battle to be seen promptly, and if they ring NHS 111, they will probably be told to go to A&E; so once again, what’s the disincentive for them?

Complex issues cannot usually be solved with simplistic sticking plasters, so whatever single concrete suggestions are made will not be enough; indeed, given our track record, playing around with the system (any system) in a ‘quick fix’ sort of way often compounds the problems, and puts different parts of the system under strain.

However, applying a deliberately opaque and undefined solution, whilst harder to quantify and assess, does allow the system (and particularly individual professionals within the system) to use such a solution constructively and effectively, and to feel more involved in that solution; ownership is a recurring theme in all the current manipulations of the public sector.

Thus, giving Acute Trusts a new process measure to meet, such as a new Trolley time target would merely stimulate a new ‘gaming’ solution (what is the real purpose of medical assessment units, for example, if not to take the strain off the A&E four hour target?).  However, contracting with the CCGs for an outcome measure of reduced admissions (and giving them control of the resources currently involved) would allow them to be inventive and innovative in their approach, involving their own professionals, and letting them see the direct benefit to patients, to hospitals, and yes, to their bank balances too.

The GPs who are involved in running CCGs aren’t bad at understanding health and illness, and the ways in which patients are involved (or not) in their care; they are also infinitely practical and pragmatic, so if given the tools to create a solution to a problem with which they empathized, then we might begin to see some progress.

Without their ‘buy in’, no single prescription can ever work, even for Bruce Keogh and Stephen Dorrell.

 

This piece is based on one first published in Pulse Managazine on 24 July 2013, entitled ‘Another sticking plaster for the A&E compound fracture’

If you go down to the A&E, there shouldn’t be any surprise….

Teddy bearsOur increasing use of hospital services is out of control and unsustainable, and is contributing to the current crisis in accident and emergency (A&E). But the problem isn’t new and 30 years of NHS reforms have tried – and failed – to control it.

We now have figures that show a million more people went to A&E in England between February 2012 and January 2013 than had done the previous year – although changes in reporting may explain some of the increases we’ve seen in the past 25 years. There are also reports that trolley times are routinely reaching 12 hours in some parts of the country.

Now that GPs have been given control of some £80bn to plan and pay for NHS services (it’s what Clinical Commissioning Groups are for…),  many believe they should also be able to treat as many as 30% of people who come to A&E, more appropriately, and in a way that eases the burden.

The 1990s saw the creation of the ‘purchaser/provider split’, which separated those who planned and bought services from those who provided them – i.e mainly the health authorities and hospital trusts. With this came the half-hearted introduction of some elements of competition.

But only if we properly understand the underlying issues can we develop a coherent strategy to deal with them. And these issues can be encapsulated in three words: poorly aligned incentives.

A question of supply and demand

The dynamic between supply and demand drives many aspects of the human condition, and this applies to the NHS too. It has always been demand led, as it was created to respond to and meet our health needs.

There are elements of preventative care, but they’ve never been as prominent as ‘sexy’ acute services such as saving babies or heart transplants.

However, demand for any service is based on knowledge of that service, and in healthcare (as elsewhere), this kind of intelligence lies mainly with those who provide them, who use it to drum up business. Until we knew that 3D televisions existed, we didn’t realise how much we needed one. Similarly, in the NHS, until we know that treatments are available for heart disease/depression/impotence, we don’t ask for them.

As in every other industry, the supply of health services tends to drive demand. Hospital funding has moved away from opaque ‘block contracts’ – crudely, an annual allocated amount – to a system based on ‘payments by results’. As this is actually payment for activity, it tempts hospitals to increase supply to drive up demand.

In commercial industry, demand is largely regulated by price: “I’d love that 3D telly, but I can’t afford it right now”. But NHS services are largely free for us to use.

They are also free to GPs, who control most of our access to hospitals through patient referrals – except A&E of course, where we decide whether or not to visit.

Traditionally, GPs referred cases to their hospital consultant colleagues that were complex, or needed high-tech interventions. It’s always been assumed that referrals are driven purely by clinical criteria (what patients need) and specific skills (of a particular hospital specialist), not serendipity or whimsy. Patients’ needs and clinicians’ expertise are supposed to matter – not consumer choice or doctors’ golfing schedules.

However, if the balance between supply and demand has depended on these assumptions, they have been eroded over the years; it’s been assumed that patients seek help when they need it (though the tension between ‘need’ and ‘want’ increases as we’re encouraged to become consumers of a ‘free good’ like the NHS); we’ve also assumed that hospitals respond to demand (and are not incentivised to increase it) and that GPs are professionally driven only to refer patients when there is an absolute need.

But with GPs’  contracts now based largely on listed activities,  they are less prepared to absorb the grey areas where no explicit activities or payments are described – for example a home visit to a bereaved widow.

Apply these criteria to the A&E situation and the results are obvious:

  • Patients, now consumers used to instantaneous service in other aspects of their lives, are bound to prefer going to A&E than waiting for an appointment with their GP. Not only is A&E open 24/7 but tests that would take weeks to arrange through normal channels are instantly available. Sure, the care is neither continuous or holistic in A&E, but these concepts have been increasingly devalued because they are so hard to measure.
  • Hospitals receive payment for every attendance at A&E, and get addiitonal sums if patients are then admitted to the wards. They are also punished for keeping patients in A&E for more than four hours, so admitting patients becomes a no-brainer. It’s only now, when demand for hospital services is starting to outstrip supply – and the cash to feed it – that the cracks in the system are beginning to show.
  • If there are no disincentives for GPs to refer patients into hospital then why wouldn’t they do it, when they feel disenfranchised and de-professionalised by the reforms that have been churning round them for three decades?

This is all easy to analyse, but harder to repair. The basic precept underpinning the NHS has been that it’s free at the point of delivery, so the mismatch between consumerism and the welfare state is bound to expand, unless the notion of corporate responsibility in health can be re-introduced or until services cease to be free.

One mooted idea has been to increase public awareness of NHS costs, on the basis that this might make them think twice before (ab)using the ‘free’ service.

Activity-based hospital funding isn’t sustainable, and a return to some kind of risk sharing between service providers and those who commission services (the GPs) is a prerequisite to managing demand at an institutional level.

GPs’ incentives must be better aligned so that it becomes truly in their interest (professionally and morally, as well as financially) to restrict referrals to those that are really necessary.

The biggest issue is that of managing service availability; as long as we increase the supply of hospital services (particularly in A&E departments) this will feed demand. We have responded to the supply side constraints in clinics and investigation facilities by increasing that supply, so it is hardly surprising that this has in its turn encouraged higher demand.

The obvious corollary would be to deliberately restrict services, but that would be very hard to sell politically to an already disillusioned electorate. However, if GPs and the CCGs were allowed to do what they were first intended to do, their core purpose would be to extract the optimum health benefit from the public funds allocated to NHS Trusts.

Managing demand would be high on their list, and most of them would tell you that given the right tools, they would manage to do this in a much more coherent fashion, albeit at the cost of reduced health consumerism. The challenge is to loosen the stranglehold from central government sufficiently to allow this to happen before all the breath of enthusiasm for doing anything is completely cut off. And that really is a Political decision.

This is a modified version of an article published in ‘The Conversation’ under the title of ‘A&E is in crisis because we all take it for granted.’ That piece is available to view at http://tinyurl.com/mp8esp6