Feature / Caring and sharing

In talking about new models of care, the focus is often on out-of-hospital services or the integration of acute and community services. But services that remain firmly in the acute domain will also need to change radically to meet the challenges posed by changing demographics, rising demand and tough finances. And there is broad recognition that meeting these challenges will require far more collaboration between currently individual acute organisations.

‘None of us are sustainable in our current form,’ says Debbie Fleming, chief executive of Poole Hospital NHS Foundation Trust, talking about her own trust and two partner foundation trusts. They are forming a multispecialty accountable network in the South of England as part of NHS England’s vanguard programme.

Building on a commissioner-driven review of services and a history of close working, the trusts want to ‘step up a gear’ in terms of joint working to deliver better care at lower costs. In doing so, they will come up against key barriers to change – the tariff funding system and the competitive basis of foundation trusts. But if they overcome these, they may have a lot to share with other health economies.

NHS England launched its latest cohort of new care model vanguards in September – the third wave of vanguards. The first, unveiled in March, involved 29 sites testing three broad models: integrated primary and acute care systems; enhanced health in care homes; and multispecialty community providers. The second, in July, included eight vanguards to test models for urgent and emergency care. Bringing the total to 50, these vanguards have been joined by 13 acute care collaborations looking to link hospitals together to improve their clinical and financial viability.

The whole vanguard programme builds on the Dalton review of organisational form. That review was clear that ‘there are no right or wrong organisational forms – what matters is what works’. It considered different approaches, including federations, joint ventures, service level chains, management contracts, integrated care organisations and multi-service chains or foundation groups. Many of these are explored by the latest cohort of vanguard sites.

Dalton underlined the fact that the district general hospital – established by the 1962 hospital plan – can often struggle today to meet the needs of its population. While this is well known in the NHS, ‘we are now at a point where patients and their families are beginning to understand that too’. Certainly, public involvement and support for revised service models will be key to all the vanguard projects.

However while the vanguards have been ‘launched’, most build on existing plans and work. Vanguard status is often about gaining useful central support to accelerate these plans.

Dorset plan

This is certainly the case in Dorset. Plans to take the ultimate step in collaboration – formal merger between the Bournemouth and Poole trusts – were dashed by the Competition Commission in 2013 on the basis that it would result in a substantial lessening of competition.

The King’s Fund recently warned that success rates overall for NHS mergers are low. Even so, Ms Fleming admits this ‘seriously burned our fingers’. But despite the set-back, there is a recognition that continuing to operate as individual organisations is not an option. If anything, she argues, Dorset is hitting the challenges facing the NHS earlier than other parts of the country.

‘We already serve the numbers of older people that many across the country are simply planning for,’ she says. ‘There are pockets of deprivation and stark differences between urban and rural communities, resulting in marked variations in outcomes. And we have very significant financial pressures.’

All three of the acute trusts are forecasting deficits this year of about 4% of turnover and all three expect to run out of cash around the end of 2016/17. The whole health economy estimates that by 2021 it could have an annual funding gap of more than £200m.

Ms Fleming says other system issues must be addressed. ‘As in many health systems, it is difficult for us to work together,’ she says. ‘As foundation trusts we have been brought up to compete and we’ve done so for years. The tariff and current service configurations have created many win-lose situations across Dorset.’

If the problems are hitting Dorset earlier, they have also embarked on the search for solutions sooner than others. Dorset Clinical Commissioning Group is part way through a clinical services review that, once completed, will set out a comprehensive commissioning strategy and propose how joined-up services across the whole county could best be provided from the different provider bodies.

Ms Fleming says there is already the ‘beginning of a blueprint’ built on revamped and new out-of-hospital services alongside significant changes for the three acute hospitals.

Dorset County Hospital NHS FT, in the more rural west of the county, would stay more or less as it is, although not all services might be available around the clock. But the two district general hospitals in the east would be replaced with one major emergency and one major planned care hospital. Both Bournemouth and Poole can make a case for their site being the emergency centre – following an earlier service review, Poole is already the lead on trauma, paediatrics and maternity, while Bournemouth leads on cardiac, vascular and urology. ‘We both feel strongly why it should be us, but we need to get all the arguments out on the table,’ says Ms Fleming. She says the commissioner view will be crucial and that if the health bodies can’t come to an agreement, it will be hard to expect the public to make the decision.

The clinical services review is a huge piece of work and, with consultation requirements, it is likely to be 2017 before any significant changes can be taken forward. ‘So the vanguard is a chance to take forward parts of the vision in more manageable chunks. It is about seeing what can be agreed among providers in joining up the services,’ says Ms Fleming.

With CCG support, the three acute trusts want to come together to focus on specific acute issues that need sorting, while also working on out-of-hospital service development.

Eight areas have been chosen as the initial focus: paediatrics; maternity; non-surgical cancer; ophthalmology; cardiac; stroke; imaging; and IT. Other back-office functions may also be covered. The services cover contentious areas such as maternity and paediatrics and areas where more rapid progress might be possible, such as cancer, which already has good joined-up foundations.

In total, the initial scope will cover £150m of services, involving 2,400 staff.

The trusts recognise there are limits to what they might do. A Royal College of Obstetricians and Gynaecologists report, due out next year, will influence the preferred model for maternity across the county. ‘But there is still lots that we can do, getting clinicians together and talking about current models and rotas,’ says Ms Fleming.

Imaging is definitely seen as a potential early win, especially tapping into remote reporting. The vanguard will explore whether some of this work – particularly on out-of-hours arrangements – could be shared.

Stroke is another area where the evidence for a different model is growing. At the moment, all three providers run a full 24/7 stroke services. Ms Fleming asks: ‘Do all three need to be admitting overnight? Do they all need the same specialist facilities?’ Given that the trusts already know the plans to split elective and emergency services, there is a lot they can do to think through the implications for stroke even without knowing the location of services.

‘Money flows will be critical,’ says Ms Fleming. A finance group is expected to work on the detailed financial implications of changes. She says while initial changes might be win-win for organisations, downstream there are likely to be win-lose situations – and these need to work financially. So if a trust loses income by giving up a service, it needs to be able to strip out the associated costs or have any stranded costs recognised in its broader funding from commissioners.

Current financial flows already create headaches. With Poole’s high proportion of emergency inpatient work, policies such as the marginal rate have hit it hard. ‘We and the commissioner fully expect to be contracting differently in the future,’ says Ms Fleming.

There is recognition that the plans are ambitious, albeit necessary. At their vanguard presentation ahead of being selected by NHS England, Dorset County chief executive Patricia Miller described the situation as having ‘a burning platform, but a credible plan’.

Orthopaedic alliance

Another vanguard, creating a National Orthopaedic Alliance, will explore a different approach to collaboration. NHS England says the vanguard aims to create a ‘UK-wide franchise or chains of orthopaedic providers to deliver outstanding and consistent care in more areas’. Rachel Yates, the vanguard’s director puts it slightly differently. ‘We are proposing to create a membership model that requires the attainment of a very extensive quality standard to join the membership and then support members in delivering franchised services against that quality standard,’ she says.

Building on work by an existing Specialist Orthopaedic Alliance and orthopaedic clinical quality programme Getting it right first time – run by Professor Tim Briggs at the Royal National Orthopaedic Hospital NHS Trust (RNOH) – the new alliance will initially involve the RNOH, the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust and the Royal Orthopaedic Hospital NHS Foundation Trust (pictured).

With orthopaedics representing the biggest surgical specialty in the NHS, the biggest spend and the area with longest waits, the trusts are convinced there is huge scope for standardisation, particularly in elective care. This would look to reduce complications that lead to issues such as revision surgery or long-term wound infection, and improve length of stay by greater adoption of enhanced recovery programmes and improved rehabilitation.

The trusts will begin developing and consulting on the initial quality standard, pulling together existing guidance where it exists and developing it where it doesn’t.

‘The aim is to describe what good looks like,’ says Ms Yates. ‘The premise is that enhanced quality and reduced complications will drive down costs through a reduction in undesirable activity and expense – for example, a reduction in long-term wound infections or readmissions.’

The standard will look at broad principles that apply across the board as well as drilling down into specific procedures, looking more broadly than the ubiquitous hip and knee replacements – for example, upper limb services, foot and ankle or bone infection.

The alliance would also develop a way of measuring performance against the standard, which would then be assessed by peer review.

‘In a year’s time, we would hope to have the organisation formalised and the process of setting standards well under way, with membership growing,’ says Ms Yates. While the broad aim is to support excellent services wherever they are provided, she admits the process is also likely to lead to discussions about where complex services are best provided at scale, although that is not the driver of the project.

Foundation group

In the North West, Salford Royal NHS Foundation Trust and Wrightington, Wigan and Leigh NHS Foundation Trust (WWL) are planning to create a foundation group. They would remain as separate FTs but commit to share decision-making, create standards and potentially share each other’s services.

Again, clear standards are central to the plans, as is the belief that better care can be provided at lower cost if some services are delivered at scale. The trusts already share a pathology service and want to look at how a group model could deliver operational excellence: providing integrated care on a locality basis, supported by single shared clinical services for acute care across hospitals serving a larger geographic population.

The two trust chief executives, Sir David Dalton (Salford) and Robert Forster (interim, WWL), told Healthcare Finance in a statement. ‘We believe [high-quality care] can be achieved through standardisation and supporting staff to deliver the right care at the right time and in the right place. We want to … look at developing shared decision-making, shared standards and, where appropriate, shared services. By doing this we believe we can reduce variation in patient outcomes and enable our trusts to increase their productivity.’

Chris Naylor, a senior fellow in health policy at the King’s Fund, says earlier work by the think tank on hospital reconfigurations suggested hospitals were in the past more likely to opt for closing or downgrading a service than exploring partnerships with other providers. But he thinks things are changing.

‘We are seeing something of a mindset shift in the acute sector,’ he says. ‘Rather than the emphasis being on growth and competition, there is a new mindset that says: to survive as acute hospitals, we need to work alongside community partners and other acute hospitals in the context of collaborative systems of care.’

Mr Naylor says more examples of collaboration are emerging and some hospital leaders expect to use arrangements such as franchising, joint ventures, visiting services and networks to deliver core district services such as general surgery, maternity and paediatrics.

In this context, the acute collaborative vanguards are timely and should help the service fast-track any learning and sharing. But in many cases, they are breaking new ground – local health economies and national leaders may need to be patient before they see significant changes in service delivery.