Time to stop shuffling the deckchairs around
Dr Joanne Medhurst explains her new role co-ordinating whole-systems transformation and averting unintended knock-on effects from commissioning decisions
To make significant savings in the NHS without simply cutting costs, we need to dramatically transform how we provide care. But a trap we have fallen into in the past is to fiddle with small parts of healthcare – the closure of a ward or moving a clinic from hospital to the community – without considering the impact those changes have on the rest of the system.
To meet this challenge in south-east London, we have set up ‘The NHS in outer south-east London working together' programme to have oversight over what happens to the whole health economy when you squeeze the balloon in one place.
I am heading the project, which brings together Bexley, Bromley and Greenwich PCTs as well as Oxleas Foundation Trust, South London Healthcare Trust and Bromley Community Interest Company.
Each organisation will be responsible for delivering its own cost improvement programme or QIPP plan and for commissioning the best services for its local population, but will share strategic decisions at the Bexley, Bromley and Greenwich clinical strategy group, which meets monthly and is attended by the clinical chairs and managing directors.
My role as programme director is to co-ordinate those decisions and check we are not inadvertently making something worse by passing costs or pressures on to another part of the system, or by simply duplicating resources. We are all working to the same goals – to improve clinical quality, service performance, patient experience and clinical outcomes, to support productivity and transformational initiatives and to remove costs from the local health economy.
Learning from the past
We have worked together on large, system-wide projects before. An example is the ‘A picture of health' programme in south-east London, which aimed to bring care closer to home, concentrate specialist services such as A&E and maternity in fewer locations and to separate elective and emergency surgery. The project completed in 2009 and was led by Bromley, Greenwich & Lewisham PCT and Bexley PCT.
In my working lifetime, our local health system has always been under financial pressure. The ‘A picture of health' consultation was focused on acute hospital reconfiguration rather than looking at the breadth of service that contributes to the whole patient journey.
After a long consultation and independent review, the eventual tipping point became about patient safety after a hospital struggled to redesign essential services because of the prolonged planning debate. The result was the partial closure of Queen Mary's and Sidcup, which lost A&E services, a labour and obstetrics ward and paediatric inpatient beds.
The commissioners have been proactive and far-reaching in their commissioning of community services, but have come to realise that working together has a higher degree of impact for the whole system.
Health is not a linear system – it is complex. My job is to look at how commissioning decisions join up and affect the whole system, and that breaks down into looking at three elements.
First, there are service changes agreed as part of the acute contracts agreements. For example, imagine you have to keep an A&E service running. The management of trauma services requires a certain infrastructure and staff mix, so even if you move all elective care into a more cost-effective environment – perhaps in the community – you may leave the hospital with the bulk of its costs but less activity and income. From a system perspective, you have added costs.
Second, there are the big service redesigns affecting the care of a defined population. For example, care for people over 65 is likely to be the biggest project we will focus on. Those types of transformational projects will not work unless we look at the system as a whole, and include social care.
The third element is to have an overview of system enablers, by which I mean issues around demand and resource management such as data tools and IT.
In the new world of clinical commissioning, the place of system management is not clearly defined. Currently, that strategic role would be down to the SHAs.
If you have one hospital – for example, in a rural area where everyone refers to the same place – it may not be so much of an issue. But in an urban environment where there are multiple hospitals, a co-ordinated approach is required.
Leaders of the health communities face difficult choices during times of austerity. We are endeavouring to save money by improving quality and by delivering care in lower-cost settings. The most obvious way to save money might be, on the face of it, to close a hospital. However, if this was a like-for-like change – in other words, just moving to another provider – then really you are just moving deckchairs around.
If you are doing things differently, you have to focus on the impact of the wider system. Care for people with diabetes is a good example. The focus is very much on moving care into the community – but if you still need to have inpatient services for people with diabetes, you need to retain some services and expertise within the hospital.
The key will be working together, openly and clearly setting out a process that achieves the optimum service configuration.
The to-do list
Our joint agenda includes eight areas of work:
• looking at the ratios of new:follow-up appointments
• reducing the number of repeat follow-up appointments
• reducing length of stay
• reviewing the use of clinical tests and the diagnostic gateway
• assessing hospital-generated referrals and consistency of GP referrals
• reducing inappropriate emergency admissions
• reviewing the common drugs formulary
• use of hospice beds in end-of-life care
• redesigning neuro-rehabilitation services.
Each of the boroughs will retain responsibility for their own commissioning, but will have agreed a shared, overarching, strategic vision.
This is not about us doing everything together. We will still be using the competition agenda to drive better commissioning, if appropriate, to achieve the best service delivery for patients in the three boroughs.
My role is to co-ordinate those decisions with the providers and to check that decisions will have the desired impact across the whole system.
One very serious issue is the financial stability of the South London Healthcare Trust. The recent appointment of an administrator by the secretary of state for health took us a little by surprise – but may strengthen this approach.
This is unknown territory, but whatever the future configuration I hope we will build a solution by working together. These care pathways will exist whatever the outcome to the hospital management team.
I trust the local clinical community will focus on the care of patients and to help design a system that is better than what has gone before.
We have also seen a raft of public protests over the management of the trust and the closure of Queen Mary's and Sidcup A&E, and there are more difficult decisions ahead. We very much want patients to be involved in the decision-making process, but we as local commissioners must balance choice, best-quality outcomes and convenience.
Bexley, Bromley and Greenwich do have a long history of working together. We used to be one health authority and now some contracts may still be shared by two or three boroughs.
But we have not done joint working on this scale, including all the commissioners and providers. Our culture of working together has strengthened. I do feel we are working more collaboratively, and that is part of what I hope my role will facilitate and build upon.
There may be a need for trade-offs, but we are going to have to make this change with openness, transparency and trust.
Dr Joanne Medhurst is a GP and former joint managing director of Bexley NHS Care Trust. Her new role is transformation director for Bexley, Bromley and Greenwich