A system response to provider failure: does Greater Manchester point to a different future?

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Regulators have a number of options at their disposal in dealing with NHS providers that get into difficulty. These include putting providers into a special measures regime, replacing the chief executive and sometimes other board members, and merging trusts with neighbouring providers that are performing well. Appointing a transformation or turnaround director and buddying with high-performing trusts are other options, as is the appointment of a trust special administrator in particularly challenging contexts.

Evidence suggests that these options have been used with mixed success. All the more interesting therefore to observe the emergence of hospital groups in some areas of England and the way in which Greater Manchester has intervened as a system to support the troubled Pennine Acute NHS Trust following the departure of its chief executive. Both developments point to an alternative form of support based on collective action drawing on local resources rather than external expertise.

Support for Pennine Acute NHS Trust, which runs four acute hospitals, is overseen by the Greater Manchester Improvement Board, chaired by Jon Rouse, chief officer of the GM Health and Social Care Partnership. It is being delivered by Salford Royal Foundation NHS Trust, under a management contract. Manchester University NHS Foundation Trust is working with Salford Royal to provide support to North Manchester hospital.

These bodies are working with commissioners and regulators and are lending their management and clinical expertise to address challenges identified in a Care Quality Commission inspection. This includes medical specialists from Salford and Manchester University trusts working in North Manchester to tackle the causes of some of its difficulties. The dissolution of the trust and merger of its hospitals with Salford and Manchester University trusts is likely in the longer term.

While it is too soon to assess the impact of this way of working, it points to a future in which provider failure may be seen as a system, rather than organisational, responsibility. Greater Manchester is of course well placed to pioneer such an approach because of the collaborative approach that has begun to develop across the conurbation through its work on devolution. Caution is needed in overclaiming for achievements so far and their relevance to other areas but the outlines of an alternative future are beginning to emerge. 

Enthusiasm for system working needs to be tempered by recognition of the risks involved. These include risks to the performance of providers giving support linked to the demands made on their leaders and clinicians. The lack of additional resources to address immediate shortcomings in care in providers receiving support, such as staffing shortages, should also be acknowledged. 

The eye-watering sums used to facilitate previous trust mergers, sometimes running into hundreds of millions of pounds, are no longer available. This may affect the willingness of trust boards to acquire neighbouring trusts in difficulty in the longer term. The willingness of regulators and politicians to continue endorsing these developments will hinge on being able to demonstrate that they have the desired impact. 

A further challenge is developing a management model for hospital groups and merged organisations that cover several sites. The well-publicised problems facing Barts Health NHS Trust provide a stark indication of the difficulty of bringing together quite different hospitals in a single organisation. Whether experienced leaders are willing to step up to this challenge and able to deliver on it remains to be seen.

A potentially positive aspect of system interventions is the ability to tackle causes of provider failure that lie beyond the organisation in difficulty. These causes may be found in the provision of general practice and community health services and in the availability of social care. Lack of co-ordination between these services may mean that hospitals face chronic problems that are not simply not amenable to changes in their leadership or mergers. 

In this respect, what is happening in Greater Manchester is different from developments in Birmingham, Mid Essex and in the Royal Free Group where the principal focus is on hospital performance.

The conclusion this suggests is that reframing provider failure as a system challenge may lead to more effective and sustainable solutions than continuing to focus on organisations. If this is the case, then other areas of the country will need to develop the capability and confidence to intervene as a system when providers get into difficulty. Some sustainability and transformation partnerships and emerging accountable care systems are well placed to do so – South Yorkshire and Bassetlaw being a case in point – and they will no doubt be watching developments in Greater Manchester with interest.

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