Older people's commission identifies problems, not solutions

You could summarise the key points of the report from the HSJ/Serco Commission on Hospital Care for Frail Older People as follows:

• Schemes outside of hospital will not lead to savings in acute hospitals – so commissioners should not think they can reduce funding for hospitals.
• Better community and social care does not lead to less demand for acute hospital beds – so commissioners should not think they can reduce funding for hospitals.
• It is not possible to meet two-thirds of the funding gap through productivity and prevention – so savings targets on hospitals are unrealistic.
• Commissioners must ensure adequate community provision – despite not reducing hospital expenditure, it is still the job of commissioners to invest in community services.
• Hospitals must provide the best care for frail older people who are admitted – if funding is not reduced, hospitals should deliver care better than they do.

That’s not what you would describe as a problem solving report. 

I suppose there is a place for pointing out where plans appear to be built on sand, and there are some very valid concerns raised. 

The integration of health and social care is clearly not a “silver bullet” for the NHS’s financial difficulties, and it takes far more than putting budgets together to make integration a reality.

That said, you would think that this self-appointed “influential group of health leaders” might have come up with some form of alternative, rather than simply proclaiming the status quo to be both necessary and inevitable.

The report was produced by the commission, but it contains no one from a commissioning organisation and is chaired by the chief executive of a hospital. 

• Download the HSJ/Serco Commission on Hospital Care for Frail Older People report
• HSJ/Serco Commission: Further evidence supporting commissioners’ key findings
• Commission on Hospital Care for Frail Older People: further reading
• Video: What went wrong with Mrs Andrews’ care

Empty pockets

To be fair, the report is aimed more at “political leaders” than commissioners. Nevertheless, it does fail to grasp the fundamental issue that the country is broke and can’t afford to throw money at the NHS in the way that it did in the past.

‘The fundamental issue that the country is broke and can’t afford to throw money at the NHS in the way that it did in the past’

It is OK to argue that current plans – or “messiah concepts” as this group call them – will not work if viable alternatives are suggested. But the report focuses on what won’t work rather than what will. 

It takes a “not my problem” approach to the national economic crisis, while presenting a thinly veiled case to protect resources for hospitals.  

Time sensitive

The timing of the report is also significant. It comes as the commencement date for the better care fund – when health is to transfer significant amounts of money to social care on the proviso that money is released from acute care – looms large and at the point when commissioners are just starting contract talks with providers for next year.

This report looks very like an attempt to “reposition” the hospitals, and has the potential to be the start of something wider whereby hospitals develop their collective voice apart from the wider NHS. 

The publication of the report coincided with the Foundation Trust Network conference, and a renaming of the Foundation Trust Network as NHS Providers. 

It would seem that battle lines are beginning to be drawn. None of which is calculated to be helpful. 

The whole ethos of the NHS Five Year Forward View is that barriers between primary, community and secondary care need to be broken down. The publication of this report appears to be moving in the opposite direction, as secondary care builds a moat and strengthens its defences. 

No confidence

I am not sure how all this will look to a neutral observer of the NHS (I am sure Joe Tibbetts will tell me in the next episode of our ‘Reality Bites’ podcast), but I doubt it is building confidence among the general population that the NHS can solve its own problems.

The problem that hospitals cause health systems in any change effort is not a new one. Martin McKee and Judith Healy wrote about it in 2000 for the World Health Organisation in an article entitled The Role of the Hospital in a Changing Environment. 

‘[Hospital are], quite literally, immovable structures whose design was set in concrete, usually many years previously’

They said: “Hospitals pose many challenges to those undertaking reform of health care systems. They are, quite literally, immovable structures whose design was set in concrete, usually many years previously.

“Their configuration often reflects the practice of health care and the patient populations of a bygone era.”

New definitions

The forward view of late 2014 talks about new models of care that integrate hospital, community and primary care services. It requires hospitals as organisations to stop defining themselves by the hospital walls, and to turn their focus to the needs of patients right across their pathways of care. 

This is hardly new thinking. 

The Royal College of Physicians’ Future Hospital Commission recommended in 2013:

• Hospital services to operate across the whole health economy, and for hospitals to be responsible for specialist medical services inside and outside the hospital
• Care delivered by specialist medical teams in community settings
• A “clinical coordination centre”: an operational command centre operating across the health economy with links to acute, specialist and primary care and community teams

Keith Palmer, in his 2011 report for the King’s Fund, Reconfiguring Hospital Services: Lessons from South East London, said that hospital reconfigurations should be designed “along patient pathways involving specialist/tertiary hospitals, district general hospitals and primary care providers”. 

And if we recall Michael Porter and Thomas Lee’s premise in The Strategy That Will Fix Health Care (which we discussed in a recent article and podcast) that care needs to be organised into units responsible for the full care pathway of a patient’s condition, we now have multiple reinforcements of the outline of the models in the forward view. 

Breaking down barriers

Hospitals need to move away from being an end in themselves, and must work to develop into organisational entities that break down the barriers between themselves and those around them.  

The problem with the HSJ/Serco report is that it does not support this way of thinking. It doesn’t even conceive of it. 

‘Hospitals must work to develop into organisational entities that break down the barriers between themselves and those around them’

It represents yesterday’s thinking stuck in the problems of today, and unable to connect with any coherent vision of the future. 

Much as they might want to, hospitals cannot operate in splendid isolation from the rest of the system any more. Reports such as this do little more than reinforce the difficulty of making the changes outlined in the forward view a reality.

Dr Ben Gowland is chief executive of Nene Clinical Commissioning Group. A version of this article was first published by The Information Daily.