More restructuring needed?
Civitas, 26 February 2009
The recession is likely to drive a radical restructuring of London’s health economy, was the message conveyed by Professor Steve Smith (CEO of Imperial Healthcare NHS Trust) and Sir Robert Naylor (CEO of UCLH NHS Foundation Trust) at a seminar organised by Civitas today.
Just as other metropolitan areas, such as Birmingham and Manchester, have undergone significant downsizing in terms of the number of organisations serving them, so must London. The current dispersion of services in the capital across 41 NHS Trusts/ Foundation trusts and dispersion of commissioning across 31 Primary Care Trusts (PCTs) is likely to be unsustainable; and, as the money gets tight, mergers will be inevitable as the cost of duplication becomes clearer.
More widely, the NHS, must seek to leave behind the primary-secondary-tertiary divide behind and open up to more flexible and integrated ways of working across the three ‘sectors’. Pitting one against the other – as the current framework tends to do – is not helping anyone.
A part of this reconfiguration, where high-performing academic and health care institutions exist, will be development of Academic Health Science Centres (AHSCs).
While the UK, said Professor Smith, has some of the best scientific and medical research centres in the world, such as Imperial, UCL, Oxford and Cambridge, the best NHS hospitals do not compare favourably in terms of clinical outcomes. The NHS, in essence, has a poor track record in translating research ‘from bench to bedside’. For 60 years, he contended, isolated university departments and isolated NHS organisations have not delivered for patients. We need new ways of working.
AHSCs, in bringing university departments and hospital trusts together under one umbrella – either in a single, integrated, structure such as John Hopkins University in the U.S. (now being developed by Imperial Healthcare NHS Trust) or more of a federated model such as Harvard Medical School (now being developed by UCL Partners) – offer such a way.
Both Imperial and UCL Partners, though using different structures, aim to provide integrated, collective leadership towards three goals: world class research, education and clinical outcomes. Imperial intends to focus on four key areas: infection; chronic inflammation; endocrinology, metabolism and diabetes; and cardiovascular; and three cross-cutting technologies: genetics and genomics; imaging; and health technologies. UCL Partners on: eyes/vision; cardiac; neurology; infection; immunology; women (and, provisionally, cancer, population health and mental health).
Above all, however, it is about translating research into outcomes for patients. It is not about self-serving super-trusts, insisted Sir Robert; it is about how best we can serve patients. Professor Smith concurred. The measure of success, he insisted, must always be about making a difference to clinical services; to patient outcomes and to patient satisfaction. The best in the UK should no longer be satisfied with being the best in the UK, they should be benchmarking internationally, where they are currently coming up short.
The question is will those that are granted AHSC status by the DH in its ongoing review process deliver? Time will tell. For now there are many questions that need to be addressed: will AHSCs be able to overcome the traditional tensions between different departments in research and clinical practice? Will they be able to develop self-improving cultures of success? Will they getting distracted by racing up the Thompson Index? What are the implications of the DH taking ownership of the ‘brand’? And, with such large organisational structures, will it become all too top-down and bureaucratic, stifling individual initiative?
More widely, how do AHSCs fit into the overall structure of the NHS, with its emphasis on marketisation, rather than collaboration? Will commissioners become ever-more underpowered vis-a-vis providers? How will the specialist research and activity of AHSCs be funded amidst tightening budgets (as development costs will be above tariff)? How will duplication of research be avoided? And will it just pull more resources into big hospitals (necessary for specialist care), when wider trends are towards integrated services and doing more in communities? What, also, of all the valuable research currently being carried out in primary care?
Above all AHSCs must keep their eye on the prize: patient care.
The presentations made by Professor Steve Smith and Sir Robert Naylor at this seminar will be made available online, following their respective submissions to the DH’s international AHSC designation panel next week.