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Guest editorial Monday 11 October 2010: Forcing through change doesn’t work

Irwin Brown of the Socialist Health Association looks at federation (because nobody else is).

The recent editorial in the HSJ raises the issue once more of hospital closures. We have to grasp the nettle and shut down the surplus capacity in dramatic gestures, it suggests, as the sustained long-term decline in bed numbers is not enough.  It even goes on to suggest that in November, the publication of the QIPP plans of SHAs and PCTs will tell us where closures will be, how many beds will be lost and how many staff, managers and front line, will be lost.

And pigs will fly past.

There is some justification, and it has been well argued elsewhere, that in some urban settings, where spare capacity exists nearby, there could be fewer hospitals (though of course filling any spare capacity in an embarrassingly expensive PFI hospital takes precedence).  Regrettably, there is the irritation that closure acts against choice, and the new regulator would not like it.

And even now, directed closure would be totally against the market philosophy of using choice and competition to drive change.  Finally, it is pretty clear that closure will be contested by the locals and probably the appropriate Health Overview and Scrutiny people.  

Oh, and LaLa Lansley has promised (sic) to stop the closures anyway. Or was that last week?

We are also hearing more about the enforced progress of trusts to foundation status and community services to become social enterprises - to be John Lewis without the soft furnishings - or even to become some other rather vague sort of foundation trust.  It is that or be gobbled up by the nearest Foundation Trust.

Behind this lies the threat of what happens if they fail to make the grade.  The ‘Dear Comrades’ letters sent to the laggards is totally vague, but the threat is that they will be broken up, taken over or merged – no more NHS Trusts (despite the fact they are still creating them!).

The answer could be federation
Those of us who are sceptical about the magic powers of the market suggest a better way, which has been used successfully elsewhere in the public sector.  Federation could be the way to improve leadership and management, and to get savings from reduced management, infrastructure and overhead costs.

Federation is a process, where two or three trusts agree to work together, initially by signing up to a common clinical strategy, possibly sharing rotas and agreeing common pathways and preferred settings for some procedures; to ensure the process is clinically led.  A joint strategic board keeps the plans of these organisations aligned and looks for opportunities for collaboration on any new initiatives.  Formal workstreams begin consideration of the integration of back office functions and rationalisation of premises, diagnostic and pathology and other supporting services.

In time, a single chief executive and single medical director are agreed, and later a move made to one management team. By using the best from the two or three trusts (and perhaps with a small influx of new people), you are more likely to get better leadership - and management, salaries can even be a bit higher, due to the increased scale.

Staff terms and conditions, contracts, protocols and processes are progressively aligned. Sharing premises and services begins to be implemented. Finally, when integration of systems and processes has been achieved, the move is made to a single organisation with one set of accounts.  TUPE would technically apply, but have no relevance.  What is new is a management entity and the local identities, such as local hospital names, can all remain; one line at the bottom of the signs might say managed by XYZ FT, but who cares?

This may well take 5-6 years (as the pace of change depends on many local factors), but it avoids all the resistance and organisational upheaval of market mechanisms like mergers and takeovers, which are alien to the NHS and have a poor track record.

Big savings are on offer, as management and support services are rationalised.  Various other attempts to share services have generally been unsuccessful, often due to organisational politics. The transition can also be managed entirely locally, and for the most part makes no difference at all to the patients who still deal with their “local” hospital or clinic even if occasionally they may have some treatment at another venue.

More like partnership, less like market
Such a change methodology is more in tune with the ethos of partnership and co-operation within the NHS and less like the market, but it would still result in bigger savings and greater stability than market transactions and enforced top down closures.

And if after all this, it was clear that one hospital within the new organisation was genuinely surplus to needs then that would have emerged over a long period of consultation and engagement, led by the clinicians.  Crucially, it would be totally clear that this was a local decision made in the overall best interest of the enlarged community. It would still be tough, but actually the public is not as stupid as policymakers like to imply: you just have to take your time; take people with you; and above all tell the whole truth in a way they understand.

You may not need to do it, because closing an organisation (or two) saves more than closing a building.