Feature / The transformers

Transformation is probably a word that is over-used, misunderstood and bandied about far too freely in the NHS. But there is no getting away from it. The population is growing. And within that overall rising total there is a growing proportion of older people, many having long-term medical conditions.

New technology can mean higher costs. Measurable quality will be expected. This must be accommodated within broadly flat (in real terms) budgets. So doing more of the same simply can’t work. The NHS needs to find new models for doing the business of healthcare.

The Nicholson £20bn challenge recognises these factors. It is the estimate of the costs of the additional pressures on the service that would need to be faced if the service continued to see current activity trends and responded to this demand in the same way. Better public health could avoid some of the activity trends (for example, around levels of obesity). But new ‘business’ models are needed that provide better and more integrated support for patients and that can help avoid chronic illnesses flaring up into costly acute admissions.

Multiple drivers

In reality, finance is only part of the picture. ‘The availability of finance is always a concern,’ says Tony Whitfield, finance director of Salford Royal NHS Foundation Trust and HFMA president in waiting – he takes over at December’s HFMA annual conference. ‘But quality and safety are just as big drivers behind the need to change.

‘Existing general hospitals were built to serve populations of about 250,000. But through advances, medical knowhow has progressed and planning probably needs to be based on a larger population size of 700,000 to one million. With a larger population, the opportunity to create services around the right critical mass changes the operating dynamics.’

The need for a skilled and experienced workforce – reflecting the greater specialisation needed for modern healthcare – has an impact on where you locate services. Ease of access for patients remains a key consideration, but so is ensuring activity levels are high enough for clinicians to see the right casemix in the right numbers to develop and maintain their skills.

Sue Jacques, chief executive at County Durham and Darlington NHS FT and current HFMA president, underlines the point. ‘This is not simply a financial thing,’ she says. ‘The pressure to transform is around quality, patient experience and workforce as well as efficiency. Increasingly we are seeing the medical colleges defining what good services look like. And this, as much as anything, is what is fuelling the drive for transformation.’

Perhaps the best example of this is around stroke care, where the driver is all about better outcomes and survival rates. Greater Manchester has been in the vanguard of some of the work to provide hyper-acute services in specialised centres.

Salford is one of three centres in Greater Manchester providing a hyper-acute service, but it is the only one to offer a 24/7 service – at weekends and in the evenings, all stroke cases are brought directly to Salford. The arrangements, which have been running for more than two years, were about 18 months in the planning and a year in implementation.

While better outcomes are the focus, the financial impact needs to be understood and can be complicated. There is the initial investment and, from a commissioners’ perspective, the unit price goes up in line with the best practice tariff for stroke. However there should be a financial return on this investment in terms of shorter length of stay for some patients and, downstream, lower long-term care needs.

County Durham and Darlington has introduced similar changes around stroke – albeit within the boundaries of its own trust. Work that was previously undertaken at both its Darlington and Durham sites is now concentrated at Durham.

Ms Jacques says that while the clear driver was again quality improvement, cost avoidance was also an issue. ‘We haven’t seen a big financial impact as a result of the changes – although we only deal with about 900 strokes a year, so within an overall turnover of around £440m it was never going to make a huge difference. But we couldn’t have afforded to make the changes to deliver the required quality on both sites, both in terms of facilities and the right numbers and experience of staff to work in those functions.’

Both Mr Whitfield and Ms Jacques stress the need for quality and patient safety to be at the heart of change. Some transformation projects will not reduce costs, some will deliver direct savings, others will show financial benefits over time. But the service needs to plan these new models to be as cost-effective as possible and at the very least to enter into the new ways of working understanding the likely consequences in terms of patient flows, patient outcomes and costs across whole health economies. Finance professionals need to be fully involved in this process.

‘As finance leaders we need to be working with clinicians as we design different ways of treating patients,’ says Mr Whitfield. ‘We can’t just come along at the end and add things up, we need to be in the middle of the design process providing insight into whether what is being suggested will push up or reduce costs.’

There will be some challenges in all this for organisations and finance professionals and there must be a need for a coherent story about why things are changing. ‘In five years’ time, some hospitals won’t look like they do today,’ says Ms Jacques. ‘Not everything can be done everywhere. We need to take the public with us and our clinicians need to be able to explain this to the public alongside finance and other professionals.’

There are already examples of this re-engineering of services across broader patches. In Durham, a single rota is being operated within vascular services across local providers, meaning that all elective aortic aneurysms are now done at Durham, with surgeons from another foundation trust travelling to the site. There are plans to broaden the collaboration.

In September, Salford and neighbouring Wrightington, Wigan and Leigh NHS FT

joined forces to open a joint pathology service. This was in direct response to a need to reduce costs charged to local GPs.

Going forward, Mr Whitfield says Salford is keen to work collaboratively with other organisations in Greater Manchester to take forward a local ‘healthier together’ initiative that aims to design services across the whole patch that are both safe and sustainable. ‘It is probable that not every local hospital needs to provide services in exactly the way they do now and some services may be better provided from a smaller number of sites,’ he says.

The need to deliver seven day a week services – ensuring outcomes are not dependent on which day of the week someone falls ill or is admitted to hospital – and greater integration of services across different services and sectors will be key issues. In Durham, Ms Jacques says an integrated children’s service (with the local authority) has paid big dividends. The services cover the full range of health and local authority services for children including health visiting and school nursing.

‘We have single point of access and co-location of professionals within a single line management structure. From patients’ point of view, care is much more joined up and they don’t have to navigate lots of different services. We reduce potential duplication and we’ve seen some significant savings.’

Ms Jacques believes the model is replicable across the country but is keen to transfer the approach to other services in her trust. ‘We are trying to replicate something similar in health, with co-location of teams and a single point of access for patients supported by telehealth or telecare. So if a patient with a long-term condition rings a single number, they can be signposted to the most appropriate part of the system. All agencies would have appropriate information made available to them.’ Unlike the new 111 system, calls would be handled by someone with access to the patient’s records.

This is still a work in progress and is a much bigger scale transformation than the work on children’s services. But the focus on such a key cohort of patients – those with long-term conditions and often complex comorbidities – means it is crucial to the transformation programme. Not only are improvements in the co-ordination of services around these patients essential, but they are at the heart of the financial challenge facing the NHS.

Alongside integration, Mr Whitfield says that seven-day working has to be the target for the whole service. ‘There is starting to be a body of evidence that suggests in many cases the sooner you can undertake the diagnosis and start the treatment, the better the outcome,’ he says. ‘Again this may push us towards services being provided more reliably on fewer sites.’

There are obstacles to achieving this model – not least within existing national terms and conditions. ‘But it is our job as finance professional to start understanding the economic case,’ says Mr Whitfield. ‘There should be no confusion. This is not necessarily about paying people less, but looking at options for paying people differently. And any changes need to be across health economies as there is no point just one part of the system working seven days a week, while other parts remain focused on Monday to Friday.’

Pay is a tough issue as it consumes so much of providers’ running costs. Ms Jacques says in NHS-wide terms, there might be an expectation that overall staff numbers would stay broadly at current levels as the challenge is to cope with rising demand and changing demographics. But in moving more services into the community, many of the roles will be at different stages in the pathway, perhaps using skills in different ways or requiring additional skills to be developed. Wherever possible, as services change the aim has to be to recirculate staff into these new roles. But some of this will take time.

While NHS bodies have still faced the costs of increments each year, the pay freeze on annual uplifts has created a bit of breathing space. ‘Pay restraint has played an important part and we need a careful national approach on pay to enable us to continue to deliver on some of these changes in a planned way,’ says Ms Jacques. ‘If inflationary pressures get out of hand, it will make some of the things we need to do really difficult.’

Both Ms Jacques and Mr Whitfield agree that finance professionals are key players in all this change. From costing current and proposed models of delivery to supporting services to improve their own productivity, finance cannot afford to be at the fringes.

‘This is a significant challenge and finance has a major role,’ says Mr Whitfield. ‘There is no-one else going to come and do this for us – make these difficult decisions and provide the information to inform transformational change. It is not someone else’s responsibility.’ He suggests that with this particular challenge ‘we are the they’.

l Sue Jacques hands over the presidency of HFMA to Tony Whitfield at the HFMA annual conference at the beginning of December.