The NHS Transformation Unit welcomes this month’s Nuffield Trust report “Rethinking acute medical care in smaller hospitals”. We’ve been grappling with the challenge of how to balance providing excellent care for the few patients who have a high risk/specialised condition with providing high quality care for the many patients who attend hospitals, often with an acute medical presentation.
The Nuffield report is remarkably clear and simple in its identification, analysis and recommendations to the ongoing conundrum of how to both improve acute medical care and meet the ever-increasing demand at our hospitals’ front doors. The report proposes a four part “solution”:
- identifying the population coming through your front door;
- treating this population with the right skills and competencies, including those in clinical training;
- rapid decision making by a senior clinician;
- linking up with colleagues from other providers in clinical situations where they have the skills that you don’t.
These are straightforward and simple solutions. So, how come we haven’t been doing this before now?
Well, many of the 8 core design principles identified in the Nuffield report have already been developed and implemented in a number of Sustainability and Transformation Partnerships (STPs) across the country. They’re most advanced in the devolved Greater Manchester region where, over the last 10 years, what we call “shared single services” have provided the foundation for significant achievements in the transformation of acute services.
The ‘shared single service’ approach allows for two things. Firstly, the centralisation of specialist services for the few patients who need them and secondly ensuring that most patients can be treated locally and still have appropriate support should they deteriorate. This support ranges from telehealth advice, the ability to bring specialist clinicians to the patient or to transfer the patient to the specialist partner site.
Crucially, one clinical team works across the single service, with the opportunity to work at both a ‘low risk’ and ‘high risk’ site. This gives senior clinical staff the opportunity to build a range of skills and provides them with a fulfilling, varied job plan. We believe working in this way adds another approach to support the less geographically isolated small hospital.
At the NHS Transformation Unit we’ve had the privilege of supporting this work over many years and the benefits of NHS providers working together in shared single service is clear to see. The most recent example In Greater Manchester is the Healthier Together programme which has been running since 2012. Like the Nuffield report, it addresses the challenges in acute medicine, as well as accident and emergency and general surgical services. The benefits – both quantitative and qualitative are evident. The obvious ones that were anticipated and importantly that were promised to the public, are:
- significant decreases in mortality rates following major abdominal surgery;
- improvement in recruitment and retention of key clinical staff;
- faster diagnosis and decision making.
Perhaps more interestingly are the unanticipated softer benefits that are having a ripple effect across all levels of transformation, not just the acute sector. Including:
- a focus on organisational (and particularly board) development;
- cohesive and collaborative working across clinical teams and organisations;
- sector wide (across several Foundation Trusts) clinical improvements such as new ambulatory care working, networked GI bleed rotas and new MDTs.
All this supports the case for working in collaboration rather than competition.
So, what’s a good alternative to “big bang” major acute reconfiguration? Closure of services is not always the answer and we agree with our Nuffield colleagues that there’s no single way. Could the approach taken across Greater Manchester in relation to “shared single services” be one of these? We believe it is and are taking this approach to other STPs who are just beginning their journey.