The NHS can’t afford to put everyone in turnaround

Sixty-five groups of NHS providers submitted plans over the summer, many of which are meaty and ambitious, for working together. Thirteen of these today are crowned as national vanguards.

For optimists, this represents a fundamental cracking of the thus far impregnable walls protecting NHS trusts’ habitual isolation – cracks that will spread and shatter the independent local hospital model altogether.

‘The plans reveal a promising and diverse range of approaches to collaboration’

Reading the last rites to local hospital autonomy is premature, but the details of the plans reveal a promising, thoughtful and diverse range of approaches to collaboration.

A proposal by the Royal Marsden, Christie and University College London Hospitals foundation trusts is a long overdue bid to build on the success of cancer networks. Radiology networking in the East Midlands and a bold franchise plan by specialist orthopaedic trusts are both particularly appealing as responses to ongoing major performance challenges for those services.

Multi-hospital chains

The most awkward questions arise for the most headline grabbing part the work - multi-hospital chains: how much time can providers spend strategising on geographically spread chains instead of working with local partners and public on challenges? Are chains simply delaying mergers, and can they really deliver substantial cost savings? Is there any trust in the country that has enough senior capacity to make it work?

The vanguard programme backs three acute organisations as capable of grappling with these issues as any.

As with all the vanguard projects, the most pervasive threat to the collaboration work is the potential to be eclipsed by day to day fire fighting on finance, performance and care quality. At the extreme, trusts in turnaround lose the headroom, spirit and drive necessary for looking outwards and for transformation.

‘It’s a common approach for organisations labelled as failing to enter turnaround mode’

This problem is illustrated in comments to HSJ by Keith McNeil, who resigned as chief executive of Cambridge University Hospitals FT over financial failure and an “inadequate” inspection rating.

Dr McNeil – who has been praised for his open, partnership approach – predicts Cambridge’s work on collaboration with other providers will now be delayed for several years as it focuses on “recovery”.

It’s a common approach for organisations labelled as failing to enter turnaround mode, to put the brakes on adventurous thinking, and focus on getting a grip of the basics. Good senior management is a fundamental necessity, and it appears this was lacking at Cambridge.

The problem is that the sheer proportion of NHS providers now in trouble means that, as a heads-down approach is adopted, change is being frustrated across swathes of England.

The paralysis is reinforced by the frenzied, often futile regulatory activity triggered by organisations falling into pre-failure regimes, establishing an industry of assurance demands and externally imposed instructions and turnaround directors.

It’s as impractical as it is demotivating – central organisations don’t have the capacity or ability to direct the entire sector, even if throwing away local responsibility and autonomy were at all desirable.

The problem is compounded by the impact on leaders of the utterly daunting scale of the challenge in most trusts, particularly to get finances back on track.

Realistic goals

Reversing this dynamic will be an early measure of the incoming NHS Improvement chief executive, and will mean raising the bar for triggering regulatory intervention, while avoiding a political or public backlash for doing so.

A starting point would be flexing enforcement of the accident and emergency performance target, in the same vein as changes made to elective standards in spring.

Providers could be set achievable short term financial goals, such as stemming growth in overspends, rather than treating each and every deficit as failure. Forgiving some trusts’ debt may also be necessary.

This would have the added benefit of making the challenge realistic, rather than leaving both management and clinicians wondering why to bother fighting when their battle is unwinnable.

‘The aim shouldn’t be to hide problems but to stop exacerbating them with regulatory overreaction’

A further option is to be more hesitant about putting trusts into special measures, and to review how the Care Quality Commission treats factors like heavy demand and limited workforce in issuing ratings.

HSJ has supported the need for a robust, trusted and fair inspection regime, and only adjustments that support this would be wise. The Addenbrooke’s row has intensified pressure at the top of the service for such changes.

These moves would spark complaints about lowering standards and problems being swept under the carpet. For this reason, they should be accompanied by increased - not reduced - transparency on quality, performance and finance.

The aim should not be to hide problems but to stop exacerbating them with regulatory overreaction.