A safe and sustainable solution to the long standing problems confronting care in Staffordshire must be found. Problems at Mid Staffordshire Foundation Trust (MSFT) have led to the instigation of the Trust Special Administration process (TSA) but there are also serious doubts about the sustainability of University Hospital of North Staffordshire (UHNS), and other issues around the quality of care across the county. A solution is needed for the whole health economy.
It is accepted that the organisational form of MSFT must change – it is not “sustainable” as a stand alone Foundation Trust – but this applies to 50 or more provider organisations within the NHS. The promoted solution of (in effect) allowing UHNS to take over MSFT (or just the Stafford component) is likely to convert two failing trusts into one larger failing trust.
There is no magic solution: you would not start from where we are – solutions are messy, take time, cost money and require effective management – and there will be unintended consequences and unexpected issues along the way. The management consultant approach which assumes we can predict flows and levels of demand and then meet that demand in some optimal cost effective fashion through inspired managers is laughable.
In simple terms there must be a solution to the organisation arrangements of MSFT and a safe and sustainable solution for the use of Stafford Hospital, but simply trying to address these without a much wider whole system programme will inevitably fail.
A whole system solution should be an NHS solution, where the best of the knowledge and experience of the NHS is applied to finding solutions – not a market and failure approach where support from other parts of the NHS might be ruled anti-competitive or indeed resisted by NHS organisations looking to benefit from any failure of competitors. It should draw on NHS expertise not pay further millions to management consultants.
A whole system approach requires a shared vision and a long term strategy. It needs to be based on the Joint Strategic Needs Assessment and the commissioning intentions for health (unknown) and social care (vague). It must be acknowledged that with an unstable provider landscape and a raft of weak new health organisations (especially the two CCGs and the HWB) some system level leadership is necessary.
This is an opportunity for finding more imaginative and comprehensive solutions, learning lessons which could be applied across the country, based on the realisation being reached across the NHS that integration is the essential component of long term stability. This requires a wide consensus and support from the community, but the TSA approach in South London has led to confrontation and legal challenge and a proposed solution with little or no support. In Staffordshire there has to be a solution which is supported by the community, the wider stakeholders and the workforce. The community has shown that they will actively resist unsupported change, and delays, costs and energy will be expended on conflict not progress.
The route to sustainable solution has to be through better service integration across health and social care and across the all various NHS organisations. Delivering such a solution will take 3 – 5 years, will require some investment, subsidies (debt write offs) and changes to standard payment mechanisms and an overarching Programme Management structure. System leadership must come through a strategic board (or programme board) with representation from the various organisations, key clinicians and community and workforce representatives overseeing the transformation programme. It all begins with a coherent clinically informed vision for the desired end point.
Control over what will need to be a significant stream of additional funding will give the board its power. As is being acknowledged elsewhere, the system leadership must have flexibility, for example to opt out of key policy levers such as tariff and procurement rigidity, with ability to pool budgets and share posts and bend governance arrangements (eg FT status).
The (disputed) history of Stafford Hospital is largely irrelevant to possible solutions; the broadest consensus asserts that clinical quality issues are not the imperative for change and so far as anyone can judge the quality of care at Stafford is good. There is no doubt about the need for a clear focus on quality of care but as the Frances Report demonstrates cutting staff, failing to listen to staff and having a staff that are disengaged and demoralised will lead to poor care.
The concern of the community in Stafford is that the current services delivered from Stafford Hospital should be made safe and sustainable; the proposals so far are to cut services significantly, to only deliver an arbitrary set of services. The assumption is that for other services patients can go elsewhere as there are “competitors” nearby willing to accept the patients as they get the tariff payment for them. This is again the management consultant approach. If a facility is shut all that happens is the patients will go somewhere else leading to economies of scale. But patients may not respond as the management consultants predict1.
The alternative argument is that safe care can be provided from Stafford Hospital if the costs are met! These costs may be marginally greater than some arbitrary average but this is still cheaper than other solutions. It is both affordable and value for money. Crucial to this however is that clinicians see that there is a future in which they wish to participate and so Stafford can attract and retain the necessary highly skilled staff. To meet ongoing professional development requirements some of these staff will need to “rotate” across a larger organisational entity than just Stafford – in an NHS based on values like cooperation that is possible. A combination of use of modern communications technologies and of clinical networking can minimise “isolation” and allow local staff to obtain specialist advice and support 24/7 services, making a smaller facility safe and viable.
The key to protecting services at Stafford is 24/7 Emergency Care and the Intensive Care Units (ICU) this requires. ICU deals with patients with the most severe and life-threatening illnesses and injuries that require constant, close monitoring and support from specialist equipment and medication in order to maintain normal bodily functions. They are staffed by highly trained doctors and critical care nurses who specialise in caring for seriously ill patients. The lights stay on and they operate 24/7.
The proposal being strongly promoted is to downgrade the facility at Stafford to just a High Dependency Unit (HDU). HDU is for patients who require close observation, treatment and nursing care that cannot be provided on a general ward, but whose care is not at a critical enough level to warrant an ICU bed.
But if there is no ITU then others services cannot be supported leading to the domino effect of first halving the range of services as proposed and then inevitably the next stage of closure of the whole hospital. The community knows this instinctively.
In terms of finances great caution is required. Projecting finances, levels of demand, workforce requirements and costs are notoriously difficult and many PFI projects based on overoptimistic assumptions (everyone signed up to!) stand as testament. In simple terms the current MSFT has had expenditure in excess of income of around £15m (around 10%) for some years; allowed to continue thanks to subsidies from the wider NHS system. There is some analysis to suggest that under some reasonable assumptions this gap might be reduced perhaps to £5m but obviously continuing subsidies are required and so MSFT is “unsustainable”.
However it takes little to show on equally plausible assumptions (guesses) how that residual gap could be closed if a wider system approach took out more of the overhead and management costs, and activity/income was rebalanced across various settings.
What nobody has worked out is what the alternatives will cost, although it could well be more. Other local facilities are not meeting access targets so obviously they cannot just absorb additional patient flows without implications – which may require investment or entail additional costs.
And what of the need for local services – the human cost of more travel and greater uncertainty. The CCG commissioners appear to have been told they must say they will not pay over tariff – they will not subsidise local services as people can travel a bit further and get treatment at the same tariff cost – so why pay more? But “local” has wider value in terms of health equality, reducing anxiety, increasing access and these and other compensatory benefits have to be factored into the cost/benefit analysis. One view is that there is a subsidy the other view is that the cost is worth the benefit.
As regards the other loose end which is Cannock Chase Hospital the solution is to transfer ownership to an organisation which will best be able to use the potential of the large but heavily under utilised site to best advantage – leaving a few valued health services to be provided from part.
So the approach to Stafford and Mid Staffs must be:-
- patience and honesty
- an NHS solution
- a whole system solution managed as such over 3 – 5 years
- built on consensus
- whole system cost benefit analysis
- strategic oversight and collaboration not mergers and acquisitions
- suspending some system rules (around tariff, competition and procurement)
- rebuilding the reputation of Stafford and ending the disputes
- retaining ITU at Stafford (using clinical networking to support)
- having 24/7 emergency and acute care from Stafford
- keeping all other services at Stafford (reconfiguration 3 – 5 years later)
- adopting a 5 year plan to bring Stafford into financial balance
- with some element of subsidy during the transition.
1 The Newark example is a classic. The local “A&E” which had a long history of issues around optimum staffing levels was shut based on the entirely correct assumption that better emergency care could be provided if instead everyone went to a proper A&E at a local hospital some miles distant. The result was higher death rates in Newark not lower.
Richard Bourne, May 2013