London health care: perspectives from the board

In my former role as managing director of Imperial College Healthcare Trust, I witnessed many of the challenges and opportunities that health care faces in London. In my new role at The King's Fund I'm afforded an opportunity to stand back and look at the bigger picture.

One of the questions I am often asked is: Is there a difference between London and the rest of the country when it comes to health care? This has always been a controversial question – some would say the issues are the same; others that complexities do make a difference – I’m from the latter camp.

Firstly the demography of London, and some of our other large cities, has an impact on how we run health care. The great mix of ethnicities in the city – having 150 languages amongst your patient population for example – requires consideration and a sensitive response. The wide variation in health status, often in close geographies, can also require specific, targeted responses. The high level of agency staff and staff turnover, and a wide variation in the quality of general practice also differentiates London.

Many organisations in London were created centuries ago, and a number of the hospital buildings have been constructed (or substantially and expensively rebuilt) geographically close to each other, creating higher infrastructure costs for relatively small patient volumes. The configuration of hospital services in London has changed a lot, but I believe there's still the potential for beneficial change – more services closer to patients’ homes, supported by specialist hospital services in fewer units with greater patient volumes.

Hospital reconfiguration creates many challenges, so how can we take the public and the staff with us during the transition and how do we manage the resulting services? I’ve always said you'd never see people with placards on the street corner saying 'we demand a hospital here', but if you try to take away the hospital that is there, the placards come out. It is an emotional as well as a practical response, based on what people are used to. When we have made changes in the past, we have not been good at evaluating them and demonstating that new services are as good, if not better, than they were before the changes were made. If we did that more then I think people would have more confidence in our decisions. Despite all our efforts and processes we've still got a lot to learn about communication on why change is needed, the options available and why decisions are made. The challenge of delivering major change and maintaining public confidence is great.

The scale of health care organisations in London also raises some issues and implications for the way in which you lead. Imperial College Trust had 9,500 staff, so it's impossible for any individual leader to walk about and get to know everyone. In my experience, in larger organisations there has to be even stronger clinical leadership, governance and processes, and very clear levels of delegated responsibility to ensure effective accountability to the board for patient services. Having close links through the organisation to the board requires strong clinical leadership. As a good example, the Director of Nursing and all nurse managers at Imperial had a day of operational delivery each week, while the Medical and Nursing Directors reported directly to the board on service quality, outcomes and patient experience.

In order to deliver quality care and productivity savings the need for good data and information is, in my view, one of the biggest challenges for the NHS. It's such an important part of the infrastructure and yet it is still lacking in some places. It's particularly difficult in London, with so many different autonomous organisations within a relatively small geography. But improvements are being made – for example, Imperial are planning to replace their major hardware and use that as a change management process to work in different ways and get better patient data and improved patient services.

So can we solve any of these challenges? Organisations in London recognise these challenges, and there have been some amazing successes, such as the London-wide stroke and major trauma reconfigurations. I've already said that the NHS could improve the way it evaluates what has worked and bring that intelligence together more consistently, and that's why it's so good to be working at The King's Fund, where they are evaluating with rigour some of the changes happening out there. It would be fantastic if every health economy was able to evaluate change, but unfortunately this is not always achievable.

The issues in London are wide-ranging, but we have the opportunity to make a huge change to the lives of millions of people who live here.

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Comments

#1077 Ken

See the same basic issues in other parts of the UK, perhaps the main issue is the scale and degree across the capital.

#1078 John Chater
Self-employed

London's strength – its unrivalled history as a centre of healthcare expertise and research – is also its weakness, as tradition always resists change (witness the difficulty in implementing new stroke and trauma services – Darzi reforms that the coalition eventually recognised as worthwhile – despite clear evidence that demographic changes made restructuring a necessity).
Add to its history a mercurial and impossible to define population which changes weekly let alone annually and it is clear that successful planning is almost impossible. As London is the ultimate embarkation point for so many of the UK's migrant population nowhere is there a greater need for local authority provision to be more closely aligned with healthcare services, yet the failures in integration are blatant.
Unsuccessful 'interventions' have failed to provide the coherence that all healthcare planners consider necessary, nowhere more so than in commissioning services (witness the expensive folly of the short-lived Commissioning Support for London). Likewise the expensive and much touted 'Darzi Centres' – one-stop gin palace primary care service centres – have proven to be something of a damp squib.
The relationship between primary and secondary care providers has at best been tolerable and it is difficult to see how the proposed reforms will make much of a practical difference, no matter how well intentioned the effort.

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