David Dalton: examining the findings of the Dalton Review

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  • Posted:Friday 08 May 2015

Sir David Dalton talks about: options and opportunities for providers of NHS care to reduce variations in clinical standards, financial performance and patient safety across the country; encouraging providers to look beyond their own organisational boundaries; and how high-performing NHS organisations might lend their support to providers in difficulty.


We want to understand why we have such extensive variation and I think if you do look at some of the markers, you see that range of variation which is quite enormous; whether you’re looking at mortality rates, whether you’re looking at indicators of harm for instance, those in the lower decile, if they achieved what those in the upper decile can do, they would be 4,000 fewer pressure ulcers reported in our hospitals every month.

Healthcare organisations, our structure organiser rooted it within this plan where the principle of the general hospital, district general hospital providing a comprehensive set of services to meet the needs of local population expressed to be about a size of a quarter of a million.

We know obviously that this struggles to deliver. When people say we shouldn’t change because it’s not in the interest of patients, we should challenge that because often what they’re saying is that it’s not the interest of their organisation. 

My offer in this particular review is the how. How could we arrange governance differently to deliver models of care? What is pointed at is not a single solution, a silver bullet, one organisational form. Indeed a number of us were fortunate to go and visit other countries, see other system in operation and as a consequence of that, we were able to discern a number of organisational archetypes or shapes.

I want to just reflect on a few of these very quickly. In the bottom left-hand corner are the ones that network solutions and a new approach of buddying, of trying to get those organisations able to show comparative success to work with those that are in difficulty and former supported relationship.

As you move up, there are then archetypes. Here I just want to pick one out, “joint venture,” and I will mention that there is no acute hospital in this country at the moment that can nor will be able to deliver the Royal College of Surgeons Standards for emergency surgery. You simply will not be able to employ the number of surgeons required. You could do it if you decided to serve a wider geographic base and create single-shed services where you’re pulling your workforce, you’re taking decisions about the use of your facilities, you may be consolidating some service but you’re creating a different organisation where two, three or more organisations come together (I call it a joint venture) with one governance arrangement to manage and lead that clinical service that’s provided across a number of organisations. So sharing risk, sharing benefit through a joint venture.  

As you move up, there are other models. We cite in the report Moorefield’s but where I’m from the Christy in Greater Manchester practiced this model too and there are many others around the country where you have specialist expertise vested in one organisation which they make available to others because they’ve got the access to skills and access to facilities and equipment that they can deploy, and I think we will see more of this as we look to find ways of providing better care at lower cost. 

As we then move up is the archetype that most people are now interest in, really doing some excellent work in thinking about how they create integrated models of care and think about the governance arrangements that they wrap around that. many organisations across the country really interest in how they do this and that’s fabulous.

And at the top right, this is a group or a chain structure where organisations see that there is benefit in coming together and operating as a single entity with one group governance structure wrapped around that.

We went all over the place, and looking at some of the problems and impediments at the moment of getting change; it took a long time to get transactions done and those organisations who have pursued them just know how laborious this can be and we came to a view that we had simplify that and make these processes much quicker if we were to see change enacted.

I’m attracted to this notion of what I’ve called “credentialing” where those organisations with a track record of success can, if they so choose, put themselves forward to another assessment system building on the ones we’ve got where judgement can be made about whether they are able to deploy what they currently do, their systems processes, methods, culture into other organisations to spread their success. 

The alternative is we can continue to spend I think an offensive amount of money on management consultancy, on turnaround, on taking top teams out and dropping in other people. You’ve got your choices. We can continue as we are with the systems and the structures and the architecture that we’ve got or we can pursue other options and get people to think through not only the model of care that they wish to pursue and redesign that; also think through the delivery systems and the governance arrangements that will make it happen and I hope that as a consequence, leaders in those Boards will see themselves now as not just stewards of their organisation, preserving the status quo but will also act to be strategic architects, to be thinking carefully about the models of care that will deliver reliable, high quality of care for their populations which means that governance arrangements, organisational shape and entities most probably will need to change.

I just think this is a really exciting time for us to be in, to encourage people to think quite differently about models of care and the way we organise to deliver those.

Thank you. 


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