Radical changes are needed – my reflections on themes from the NHS Confederation conference

Many people at the NHS Confederation annual conference last week remarked that it seemed quieter than usual. Perhaps not surprising given the current demands and pressures on NHS leaders, such as handling the doctors’ industrial action, staff facing job losses and many managers being uncertain about their own futures. These demands and pressures do not bode well for addressing one of the key challenges highlighted at the conference – the need for radical service change.

Ruth Carnall, Chief Executive of NHS London, highlighted clinical involvement as one of the keys to successful reconfigurations in London. But with staff morale approaching an all-time low, it is unclear whether clinicians have the appetite to lead major service changes, particularly in the face of public opposition. This will no doubt be the first of many farewell speeches from Ruth – including one at the Fund later this year. Her insights into the role played by strategic health authorities also exposed the gap in strategic leadership that has opened up in the restructured NHS. It is unclear whether clinical commissioning groups working together can fill this gap and drive through reconfigurations across large populations.

We have argued that the changes needed to meet the productivity gains on the scale required must be transformational. Mike Farrar echoed these sentiments in his speech, urging organisations to work together rather than in the narrow interests of their own organisations. The test of these new reforms will be whether the CCGs can engage clinicians in new ways across the primary and secondary care divide, but also engage with local authorities on public health, social care and children’s services. It is imperative that foundation trusts gain a broader vision of success – one that is not based on growth, but on delivering high-quality care and improvements to the health of the population as a whole.

It will be critical for politicians to have the courage to lead public debate about the need for hospitals to downsize and, in some cases, close. Stephen Dorrell quoted from the famous Water Towers speech, given by Enoch Powell as Minister of Health, who said, ’We have to get the idea into our heads that a hospital is a shell, a framework, however complex, to contain certain processes, and when the processes change or are superseded, then the shell must most probably be scrapped and the framework dismantled’. Unfortunately the current Secretary of State for Health, Andrew Lansley, did not show such political courage, but stuck instead to his four tests and the claim that these were matters for local resolution. In contrast, the government has been bolder this week in its decision to address the longstanding problems in South London by bringing in the administrators.

Much credit has been given to David Nicholson for naming the challenge of the £20 billion productivity gap. At this conference he came close to naming the challenge of potentially closing hospitals too, but he did not define the scale of the radical service change needed. It seems even he is unwilling to put a number on how many hospital beds will need to close.

The financial and clinical case for change seemed clear enough to most at the NHS Confederation conference, but the argument still needs to be won with the public and the wider staff working in the NHS.

It was scandals in mental health some ten or more years later that finally precipitated the changes set out by Enoch Powell in 1961. Mid Staffs and other scandals may be the galvanising force needed to finally shock the system into changing. Mike Farrar made a compelling case that instead of blaming nurses and others for the failure to care for the needs of frail older people with dementia in our hospitals, we need to recognise that it is the system and organisational context that is at fault. The model of care in acute hospitals is not fit for now, never mind the future. Nothing less than radical change will do.

The King’s Fund will be playing its part in shaping the vision for the future of care as we launch a programme of activities in the autumn with our own case for change. We hope you will engage with us in shaping a vision for the future of health and care in England.

Find out more about our forthcoming event: Progressing health care in London

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Comments

#1257 Leslie Hamilton
Cardiac surgeon (ex paediatric cardiac surgery)

Anna highlights one of the most important issues facing the NHS. The current "Safe and Sustainable" national review of children's heart surgery is a microcosm of the reconfiguration needs of the wider NHS.

The paediatric cardiac surgery service developed over the last 40 years in an ad hoc way driven by local enthusiasm and committment. However surgical techniques have changed beyond recognition and the service is no longer either fit for purpose or sustainable.

The review was requested by parents, led by clinicians and will be decided (at a meeting in public on 4th July) by Commissioners (the Joint Committee of Primary Care Trusts). Now we need the public to understand and the politicians to have the courage to see it through. If it fails there is no chance of any other service reconfiguration in the NHS succeeding.

#1258 andrew field
GP

Personally NO. I'm demotivated and too angry at government to work even harder at saving on referrals, prescribing and emergency admissions. In fact, I'm trying less hard than I was 2 years ago."

#1259 John Kapp
director SECTCo
secto.org

I am overjoyed about the new NHS, because the 64 year monopoly on provision of treatment has been broken, and SECTCo has been invited to bid for providing the MBCT course for depression. The waiting time in Sussex is 2,000 years, yet patients have the statutory right to it under the NHS constitution as it is NICE recommended. At last patients can be offered drug-free treatment for mental health in mass-provision to be able to improve public health. GPs will soon have £10,000 per day to spend on safe, effective treatments instead of harmful drugs.

#1260 Jane Swainson
Nurse Manager
Nursing home

Anyone who believes that refocusing on the original principles of the NHS recognises that difficult decisions have to be made by Trusts so that life saving services are provided over and above those which have become an expected provision.

Much money is wasted by top-heavy staffing at all levels. Senior management in particular needs to be pared down to a competent few who are fully accountable for their decisions. Wards are top-heavy with nurses, many of whom fail to lead by example by giving "hands-on" care to their patients, which is left to health care assistants. How often do we hear of nurses chatting at the nurses station while bells are waiting to be answered by patients in need of attention? Where is the leadership on the wards?

In days of yore staffing of a typical shift would comprise a senior nurse (Sister) and a staff nurse together with an enrolled nurse all of whom ensured good practical, knowledgeable care of their patients and also supervised and mentored student nurses as part of the hands-on team - an experience in which current Community-seconded students nurses revel when placed at our nursing home for their community placement.

I recently interviewed a nurse for a position at the nursing home that I manage who told me that she had tried working in the NHS but she did not like what she found - that nurses did not CARE - and she did not want to be associated with that ethos.

#1261 Mike Stone

' How often do we hear of nurses chatting at the nurses station while bells are waiting to be answered by patients in need of attention? Where is the leadership on the wards?'

I read the Nursing Times posts, and interestingly they invariably claim not to have any time left for 'chatting to each other' but many nurses do not like their 'leadership', either from nurses-turned-managers, or from pure managers who are within healthcare.

The nurses often claim that they are all stretched to breaking point ! And many also add picked-on, bullied, and blamed for lots of things out of their control !

#1262 Vickie Ferns

I was in and out of hospital numerous times while living in London and all nurses worked very hard, there were the occasional nurses who were not as good as others and one who was down right cruel but she was banned from the ward once it was reported what she had done. (She was an agency nurse). I found the standard of medical care ran rings around the care I receive now in New Zealand. We have already moved to community care and I am constantly reminded how much it costs to care for someone like me, how NZ can't afford chronic patients.My G.P is far more concerned with the cost to the hospital than how much I might be suffering at home with intractable pain however I have decided I will not consult him if I feel I need antibiotics by IV to bring down the pain --I have resistance problems after 15 years of undiagnosed bacterial overgrowth of a roux-en-y loop used in liver surgery.
We too have problems with funding the building of new hospitals and like the London Hospital staff have left over mangers cutting theatre time, basic tests etc, the hospital is finished now but has been described as an Albatross, as they are on the endangered list that tells us that health care in Wellington is at risk due to the huge debt which has to be paid out of normal Health Board running costs. Why can't a lottery be started for the cost of hospital buildings if governments can't afford to pay for them.
I don't know what the answer is to the problems of rising costs of health care and an ageing population. New Zealand has a ridiculously small population with Goverments who want to keep cutting the top tax rate.
What ever changes are made in Britian I hope that if they get patients with unusual complications they still will be treated and not just left out in community care in immense pain with no one trying to find out what is wrong which is what happened to me for 12 years in NZ, at least in the Uk they never tried to make out the pain was in my head when tests came back normal and were prepared to have me in hospital when the pain was severe even if I didn't have a temperature so they could rightly try and work out what was wrong.
I was born with an extremely rare condition, when I was 18 I would have told you I was grateful to the amazing surgeon who was considered 20 years ahead of his time but at 53 there are times I wish he hadn't bothered because what I have been through has been so horrendous especially the last 15 years. (I have had 7 surgeries over my life time and a number of complications.)
I need an air mattress to take the pressure off my body as it s so hard to sleep but I'm told I don't fit the criteria yet if you look up hospital air mattresses in the USA ,intractable pain is a criteria for using them but Wellington hire them to save on storage and employing someone to fix them, so only people who would get bed sores are allowed them. I've just seen a pain team after waiting 8 months and even though my pain is uncontrolled I will not see the doctor again unless my G.P applies again and that will take another 8 months.

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