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Trusts and hospitals

Updated Thursday, 6th December 2007

Gerry Robinson's return to Rotherham General Hospital for Can Gerry Robinson Fix The NHS?: One Year On, shows how closely-bound Primary Care Trusts and District General Hospitals are – and how distant they remain, says John Storey.

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This follow-up programme is illuminating in two main ways. First, it raises in a compelling way many issues about models of leadership and management within a fairly typical District General Hospital (DGH).

Secondly, it begins to lift the curtain on a number of key contextual issues found in a wider world which have had a profound impact on the way such hospitals can operate. These two worlds, although often operating relatively separately (as the programme towards the end makes all too painfully clear), are in fact mutually interdependent. Rotherham hospital is dependent for its finances on the local health authority (now known as the Primary Care Trust, or PCT) and equally, the ability of the PCT to deliver its health care mission is heavily dependent on the hospital.

Within the confines of the Rotherham DGH Trust, issues relating to staff relationships, management control, leadership, motivation and demotivation, commitment and lack of commitment, devolved accountability, and so on, are all addressed. The tension between the general managers and the surgeons is evident. Also, Gerry refers to the tension between the Chief Executive and the consultants: indeed, he refers to the mood at one point as one of "animosity".

The programme raises the question of how professional-based organisations such as acute hospitals should be managed.

One model is to allow a profession-led approach with the senior management team, including the Chief Executive, simply 'administering' and 'facilitating' (in other words, smoothing the way for doctors to get on with their professional tasks relatively undisturbed).

Another approach is to insist on a firmer lead from the top. This is seemingly an approach closer to Gerry's recommendation – though of course he also wants the managers to carry the clinicians with them, and not simply to dictate to them.

There are other models in play throughout the wider NHS. A currently favoured one is to co-opt medics into the senior leadership team so that 'clinical engagement' with managerial issues - including the financial ones – is encouraged.

Meanwhile, outside the boundaries of the hospital, the programme allows some intriguing glimpses into the murky and complicated world of the PCTs and the institutions which exists around them.

District General Hospitals such as the one at Rotherham have been on a roller-coaster ride within the wider NHS. The creation of Foundation Trust status has allowed a degree of devolved autonomy to these institutions. Their inception was greeted with considerable optimism. Freed from the direct control of the Strategic Health Authorities and, notionally at least, given considerable freedom to devise their own strategies, they engendered considerable enthusiasm.

This 'autonomy,' however, is subject to a number of caveats – not least of which are the Department of Health targets such as the four-hour accident and emergency (A&E) wait and the 18 weeks referral-to-treatment target.

The Foundation Trusts have been incentivised to reduce costs, increase efficiency and to achieve surpluses. These surpluses they can retain and invest in new and better services. For example, Chief Executive Brian James reports a £600,000 surplus this year for Rotherham, after a £1.5 million deficit the previous year. All of this is subject, in practice, to the PCT(s) which funds these hospitals actually having the money to pay for any additional work.

In recent months the mood surrounding DGHs – including the Foundation Trust versions – has become more sombre. New 'threats' have been reported which some observers have suggested could even presage the 'end of the DGH'. This is probably an over-dramatic reading but it does capture the challenges deriving from the erosion of business from above and below.

The threat 'from above' derives from government policy which leans in favour of a limited number of centres of excellence. This initiative takes specialist work out of the hands of DGHs and places it in the hands of those centres equipped and staffed to deal safely with large volumes of work.

The threat 'from below' stems from the proposition that much routine work, such as diagnostics and simple treatments, could be done 'in the community'. This essentially means channelling this kind of work to GP surgeries or to clinics which would be staffed in various ways depending on the type of clinic. It may be a walk-in clinic staffed solely by nurses, or a polyclinic staffed by GPs and possibly on occasions by some hospital doctors. Crucially, the tariff paid for such work by the PCT would be much reduced.

Both of these trends evidently leave the DGHs with a narrowed band of work in the middle. Both of these modes of erosion of the DGH business have already begun - in varying degrees - across the country.

DGHs' remain broadly optimistic that they will retain a vital and continuing role despite these developments. In the main, they are probably correct to be sanguine. There is plenty of appropriate work to be done; it is the case that there is scope to move some work outwards, either to highly specialist centres for complex cases, or to primary care for more routine cases. The extent to which this can - or should - be done is more controversial.

As hinted at in the programme, the removal of some routine procedures to independent treatment centres and private hospitals carries the risk, however, that this could undermine the viability of DGHs which may be left only with complicated cases. The DGHs under most threat would be the smaller ones which are not able to sustain a full range of services and which do not have any specialist areas of expertise of a tertiary kind.

The underlying theory of competition and challenge in the Foundation Trust model is that the successful trusts would attract business from the weaker ones. The extent to which the Department of Health would be prepared to see hospital closures stemming from the playing out of this competition has remained a rather moot point.

The key point to note is that although these 'two worlds' (inside and outside the hospital) may seem to co-exist in a detached way, they are, in reality, intimately bound together by myriad forces. Work remains to be done to ensure a greater articulation between them.





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