Comment

Colour-coded service change

2020health.org recently launched its new report, ‘Healthcare and the economy 2: Going with the flow’. The briefing paper by chief executive Julia Manning and operations director Gail Beer looks beyond ‘the NHS must change’ mantra to actually consider how to change. Below is an extract on the proposal to ‘colour code’ hospitals as 'Red' or 'Blue'.

Public concern has been heightened by some of the high-profile debates on the future of hospitals. Threats of ‘downgrading’ have left people confused as to what their hospital will or won’t offer. Often, as far as they are concerned, their hospital is in their community already so talk of ‘moving services into the community’ doesn’t really make sense. For those who need care out of GP opening hours, it seems obvious to go to the local A&E. All the terminology now – minor injuries, urgent care, out-of-hours, walk-in – is incredibly confusing for the public.

There is no doubt that there are too many hospitals trying to offer specialist services, and this is both a drain on resources and not safe for the public. Once again we need to go with the flow, stop telling people not to go to hospital, start simplifying the messaging and enable more strategic planning. We propose starting to colour code services, level the financial playing field and involve the public much more in decision making.

National ‘Blue’ specialised hospitals

The large specialised hospital would provide for serious A&E cases and complex trauma, with emergency surgery available as well as scheduled operations. There would be 24-hour consultant cover in A&E, including for children in some. The public would know the designation by the simple labelling of specialised hospitals as ‘Blue’. Already there has been some consolidation of some specialised services – for severe trauma, heart attacks, stroke units; other specialist centres have grown up around rare disease research e.g. uveal cancer of the eye at St Paul’s Eye Unit, Royal Liverpool University Hospital. The hyper-acute-stroke-units (HASUs) were established by Healthcare for London to improve the quality of stroke care in the capital, reducing the number of hospitals that treated the public who had suffered a stroke from 30 down to eight. The death rate dropped by 12%.

To improve how and where specialist care is delivered requires a strategic overview of hospitals and an ability to make decisions based on quality and safety. A competitive market in specialist care doesn’t work: the public need to know they will receive high-quality, safe care no matter to which Blue hospital they go. This does not mean there will be a monopoly – the hospital board will be accountable for the standards of care and if services fail, they will be replaced.

Likewise there will still be ‘competition’ between services; specialist teams want to have the best reputation and the best outcomes, and this is good for patients.

Local ‘Red’ general hospitals

We need to recognise that public are not going to let their local hospital go. They like visiting it – despite the parking, the waits and the scandals! Staying in it is another matter, but that’s not what most people think about. A new vision for hospitals needs to be articulated, one that enables the public to have confidence that services they need are where they need them and when. It doesn’t mean they are all in one place.

The local ‘Red’ hospital would offer general services, with a hub and spoke model to allow some services (e.g. diagnostics) to be co-located with larger GP surgeries. Where space is freed-up by more specialised services moving to major centres, the hospital needs to work with the community on using the space for GPs, out-of hours (OOH) providers, community care including e.g. children’s centres, rehabilitation, research collaboratives, small businesses and enterprises, adult education, biotechnology start-ups and companies, university satellites, the voluntary sector etc.

Services in Red hospitals would be provided using safety as the criteria (that is, what is it safe to provide and what gives the best outcomes) and what may compromise the safety and health of the local population if it is not there, and what would enhance it.

The local Red hospital would provide simple elective surgery, with much of it being day cases. Other, more complex operations would move into the specialist Blue hospitals.

Due to all the adverse publicity, the public are anxious about their A&E services. We have lost confidence to care for ourselves and there has been a real loss of confidence in the OOH service. The public express fear about what happens at night if they need medical care, especially as many still have a problem with getting to see a GP at short notice, so many just go to their A&E. So let’s provide the services where they want to go. Providing a 24/7 emergency service in a one place can make the most of the OOH GPs, with the support of nurse consultants, emergency nurse practitioners, paramedics, social care and pharmacists. They can be the treatment or triage centre.

These centres can give advice, run education programmes on health and follow people up. The hospital would have some facilities for overnight elective surgical stays but would primarily be focused on the management of medical conditions, would provide maternity services and would have full consultant cover. People think about ‘their’ local hospital and ‘their’ local GP. We need to build on these sentiments and encourage the involvement of the neighbourhood in a meaningful way.

Enabling the reorganisation

To enable this reorganisation to Blue and Red hospitals to happen will require some brave decisions: NHS trusts with rebuild (PFI) debt will have to have it written off by the government, which would cost the tax payer about £11bn, to enable the strategic planning required for Blue hospitals. (This sounds a lot but if left to term, PFI payments will cost the taxpayers £65bn).

Every hospital will have to review its sustainability business case, and the reality is that some existing sites will not be viable, even with diversification. Some hospitals are currently ‘foundation trusts’ (FTs), which means little to the public, but theoretically gave those hospitals greater freedoms to develop. This was a nod towards the ‘mutual’ model, but without the full freedoms and potential that mutual models offer.

Despite the fact that two million people are ‘members’ of FTs, the vision of engagement and mutuality has not been realised, with little information exchange and no real public voice or representation happening. Financial freedoms given have not been used in the way they were envisaged either. FT status should be abolished, but work should start on how to really enable any hospital to develop into one of the genuine mutual models.

 The full paper is at 2020health.org

Recommendations include:

• Produce a National Financial Plan and work towards a National Service Guarantee
• Promote stewardship and accountability
• Be honest about what’s available and enable people to spend on themselves
• Enable clarity on choice
• Use technology to deliver choice
• Develop ‘payment by results’ benefits for those who make positive behavioural choices
• Initiate strategic review and development of national ‘Blue’ specialised hospitals
• Initiate strategic review and development of local ‘Red’ general hospitals
• Encourage public involvement