I want to answer this question by reflecting on the current way in which the NHS thinks about this question in theory and acts on it in practice.
There is a growing chasm between what the NHS thinks should be done to change the hospital model and what it is actually doing on the ground.
Nearly every board or leading doctor or manager in the NHS thinks that the current model of hospital care should and will be radically different in the next decade. Most people would say that this has to happen if the NHS is not going to run out of money. So the driver for change is a powerful one. Change might take the form of:
- developing integrated care pathways that have the bulk of the pathway outside of hospital moving some categories of outpatients and day surgery out of hospital, or
- removing the demand for emergency beds out of the hospital.
Sometimes this is backed by the idea of developing whole new models of care; sometimes it is backed by specific restructuring of current models of care.
But all around there is talk of radical change in the way in which hospitals operate. Most hospitals agree with this theoretical vision.
If you look at the long-term vision of most hospital boards, it contains a lot of change. If you add up the commissioning intentions of clinical commissioning groups (CCGs), together they create very different models of care for England’s hospitals.
Change – very radical change – in the nature of hospitals is in the air. The problem for the NHS is that it might just stay there – in the air. For in many parts of the country the moment a CCG starts to put this into operation a very different set of motivations comes into play.
In some of the CCG authorisation sessions that I have heard about, the second or third question that the panel asks the CCG is why they aren’t more worried about the way in which their commissioning intentions might ‘destabilise’ the hospital. Under those circumstances CCGs are puzzled. They look at the commissioning intentions that have just been marked green by the panel. They will have been congratulated because they have developed radical new approaches to integrated care in the home and the community.
But the moment they actually DO something they are told they should be more worried about destabilising the hospital.
This is backed up the possible action by the hospital at the moment when any of these intentions are put into effect. Hospitals still say that if you move these clinics out of the hospital, the hospital will collapse and it will be your fault.
In some parts of the country the old strategic health authority (SHA) (now a part of a new cluster and soon to be a part of the brand new NHS Commissioning Board) will then challenge the CCG about whether they really know what they are doing in moving this work out of the hospital.
- How would they cope if the hospital fell over?
- What plans have they got to replace the entire hospital when this happens?
It takes a brave CCG to say ’Actually whilst of course we have an input into that, it is not our prime concern.’
The brave CCG points to the new architecture and says that luckily Monitor will have the responsibility to the public ‘to ensure the continued provision of services.’ It is Monitor that will have the responsibility to look at the whole of England and see which providers are becoming unsustainable. It will be Monitor whose responsibility it will be to have plans to ensure that those services are maintained irrespective of the nature of the organisation.
My point here is that the NHS has a pretty good analysis of how the question at the top of the page should be answered. Of course it could be better; of course we probably need more fluidity in the thinking and more knowledge from other jurisdictions.
But the theoretical answer is not the problem. The problem is the practice of making the vision happen. Practically there are real road blocks placed in the way of putting that vision into reality.
Great CCGs and great provider trusts can and will get round and through those road blocks. But to radically change the hospital model in the NHS we need more than heroines and heroes.
To change something this big the whole system needs to encourage the change so that ordinary organisations can make it happen.
Professor Paul Corrigan CBE is an an Independent Consultant and Executive Coach.