The place of specialist provider trusts in the wider health economy

Source: National Health Executive Sept/Oct 2013

The Royal National Orthopaedic Hospital NHS Trust is keen to press ahead with a major redevelopment of its site to update dilapidated facilities, some of which were intended to be temporary wartime structures. NHE talked to trust chief executive Rob Hurd to discuss the progress made, the trust’s ambitions for the future and his own management style. 

The RNOH’s vision is to be the leading specialist orthopaedic provider in the UK – but an important part of achieving that vision is a major redevelopment and modernisation of the trust’s site at Stanmore in north west London. 

The plan has Government approval for its outline business case, it got planning approval from Harrow Council in March, and the trust will soon choose between two bidders for the construction work – Balfour Beatty or Boygues.

Chief executive Rob Hurd, speaking to NHE in August, said: “We are waiting for permission to call in their full and final bids, at which point we go through the final planning cycle and reach a financial close hopefully in the spring/ summer of next year – and then we get our new hospital going up. 

“It’s been a case of slow but steady progress. We had a major breakthrough at the last election with the full government approval of the outline business case and we’re hoping we don’t get to the next election without having us completed the job!” 

Hurd said most of his time as chief executive – he took on the role in August 2008 – is spent on ‘choreographing’ the journey to foundation trust status, the rebuild, and dealing with the new commissioning environment. 

The journey to FT status 

He told us: “Our major project is to keep delivering high quality, sustainable, financially-viable services. 

“As a specialist centre we score very well on the Friends and Family test, we have very low infection rates – we haven’t had any MRSA here for longer than any other hospital, so our quality there is without question. Financially, we’re currently doing fine against our targets and delivering surpluses. 

“The big issue for us is that to become a foundation trust, we have to demonstrate we’re futureproofed in this economic climate and that we can absorb the impact of a major rebuild of the hospital. 

“The NHS environment, particularly on the commissioning side, has been pretty turbulent. 

“A large proportion of our activities – 70% – are commissioned by specialist commissioning now.” Before April 1, only 10% of the trust’s activity was specially commissioned. 

Talking about the consolidation and changes to specialist commissioning that came in from that date, Hurd said: “Whilst we’re supportive of that change in the long term because we’ve now got some meaningful dialogue with one commissioner who’s a substantial player for us rather than with hundreds of different commissioners, it has created some turbulence and uncertainty. 

“I’m frustrated by some of the transitions and some of the confusion caused by the transition, and there’s a lack of clarity as to how things are all mapping out. 

“I’m sure that will resolve itself over time, but specifically it has held us back on the pace of our redevelopment by three or four months while we re-establish that commissioning support in the new environment.”

As well as the trust’s main hospital at Stanmore, it also has a London Outpatient Assessment Centre, which opened in Bolsover Street in late 2009. 

Friends and family 

Internally, the trust has been collecting Friends & Family test data for 18 months. 

The trust has a very high number of positive responses – the number of patients ‘likely’ or ‘extremely likely’ to recommend it is in the top 10 nationally – but also a high number of negative responses, meaning a net performance of around 70%. 

Hurd said: “We think that’s basically to do with our facilities and the environment we’ve got here and therefore by rebuilding our hospital we’ll solidify our place in the top ten.

“We find that the more people we get to fill it in, the better we do and our score goes up. 

“We receive very few complaints; on average about five to 10 a month out of 10,000 patient interactions, which is a very small proportion. 

“We do learn from our real time patient survey; we do have big issues around some of our admission processes, for example. 

“We’re improving communication with patients; what happens at every stage of their journey through the hospital, from outpatients to inpatients and through to discharge.” 

A shoulder-to-shoulder approach 

We asked Hurd to describe his approach to management.

He told us: “I’m a fairly collegiate chief executive; I’m very much about clinical leadership in the hospital. I’ve developed clinical leads, a medical director model where they’re shoulder to shoulder with management, putting clinicians at the heart of running the organisation. As a specialist centre, that’s what it’s all about really. 

“They are the senior people who know about the care that we provide and know how we can best deliver our vision and our aims as an organisation for patients. I would like to think that if you speak to the clinicians, they would reflect that back to you as well – that the chief executive supports that clinical lead / clinical director / medical director-led approach. 

“We have at the heart of our board a clinical triumvirate – the nurse director, the medical director and the chief operating officer – who effectively run the hospital from day to day. 

“They are on a par with each other. When we’re implementing quality improvements and saving schemes, they will only happen if the clinical triumvirate at the hospital and the quality committee on behalf of the board [confirm] there is no adverse effect on patient care. 

“Clearly when there are continuous financial challenges, we as a specialist centre have to make sure that patient care remains at the forefront. We wouldn’t exist if we made any sacrifices on quality because the activity would be broken up and done in district general hospitals, which I think would be worse for patients overall. If we don’t stay ahead of the game on quality, one of the reasons for our existence disappears. Clinical leadership is at the heart of that.” 

Academic partnerships 

We suggested to Hurd that there can be a danger of specialist provider trusts becoming isolated and inward-focused, rather than engaging with the wider health economy and less specialised parts of the NHS. 

He said: “I think there is a danger that specialist centres become ‘islands of excellence’ and isolated, so it’s very much at the heart of our strategy to expand our external profile, particularly via the Academic Health Science Networks. 

“We have a role as a leading player in musculoskeletal orthopaedic innovation, looking at new forms of treatments, improving outcomes for patients and us being the specialist hub. 

“We’ve got to do the complex work well and we’ve got to do the things that are done better at a critical mass in a specialist centre than they would be done in low volumes locally. 

“In partnership with our academic partners, University College London, we’re leading the academic side of things, developing the teaching and training consultants for the future. A quarter of consultants that have trained in this country come through this centre.” 

As an example of the new forms of treatment being developed, Hurd mentioned the multi-award winning ‘growing prosthesis’, which stops children needing to have multiple operations. 

Hurd said: “Instead, they have the implant put in and a magnet extends the prosthesis implant as they grow. It’s better for the patient, it saves everybody money and it comes out of a centre of excellence and can be cascaded across the health system externally.” 

Patient safety and economies of scale 

Hurd continued: “That’s our role in the wider system: you wouldn’t have a Royal National Orthopaedic Hospital at the end of every high street, but you’d have one in the country as the national reference centre, the place where the innovation takes place, that can be cascaded out to the wider world. We have lots of examples of that. 

“If hospitals scattered around the country are doing one or two complex implants, that’s going to cost a fortune, whereas if you do 100 or 200 in a specialist centre you get those economies of scale and it benefits the clinician who’s then doing 100 or 200 a year rather than one or two. Buying in mass is also in line with the National Procurement Strategy – getting more value for money via economies of scale.” 

Hurd and his colleague Professor Tim Briggs, president of the British Orthopaedic Association, have been commissioned by the Department of Health to look into ways of enhancing the quality of orthopaedic care in all settings across the whole care pathway – primary, secondary and specialist tertiary centres. 

Hurd said: “It’s about getting it right first time, reducing infections, and getting a better patient experience – which ultimately will save money for everybody. With the ageing population, it’s a real win-win to get a higher quality of care in orthopaedics.”

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