Presentation on theme: "Technocracy or politics? The process of hospital reconfiguration Perri 6, Nottingham Trent University and Naomi Fulop, Kings College London."— Presentation transcript:
Technocracy or politics? The process of hospital reconfiguration Perri 6, Nottingham Trent University and Naomi Fulop, Kings College London
Defining reconfiguration a deliberately induced, non-trivial change in the distribution of medical, surgical, diagnostic and ancillary specialties that are available in each hospital or other secondary or tertiary acute care unit in a locality, region or health care administrative area
Whats it for? Four stories The civil servants story: to develop innovation, flexibility, improve access The royal colleges story: to ensure enough clinicians in every centre to meet their standards of viability The clinicians story: to find a way to cope with the European Working Time Directive without service collapse The politicians story: to avoid any more upsets like Kidderminster!
Examples of DH approved reconfiguration initiatives Minor injuries units Specialist routine elective unit Telemedicine: digital imaging relay, videoconferencing, CfH, care pathway monitoring Extended roles for nurses and for non-medical staff: nurse-led clinics, pre-op assessment, prescribing Ambulatory care incl. One-stop elective day surgery, diagnostics, dermatology Dedicated routine maternity unit, e.g. midwife-led Hospital at night programmes: some generic medical roles, senior nurse coordinators Networks (all over again?)
SDO study: 3 case studies After Kidderminster and Keeping the NHS local, DH funded pilots, to be exemplars of reconfiguration At DH request, in 2004, SDO commissioned evaluations of the pilots Quantv. analysis financial and clinical data Qualv. interviews stakeholders and analysis of documents Analysis of sustainability of reconfigurations
Trust A Merger of 2 urban, inner city DGHs 1999 (500,000 pop) Significant financial issues Single site reconfiguration Senior ministerial interest Separation of elective and emergency care, and redesign of emergency care New building, decreased LoS, greater integration of primary and secondary care, simplification of patient pathway Aug 05: new building nearing completion, some preparatory regrouping within old building; intense pressure due to restructuring at the Trusts other hospital, continuing problems from merger, some clinical resistance
Trust B Merger 3 DGHs, 2002 (570,000 pop) – hospitals X, Y and Z New PFIs at hospital Z (2001) and Y (2002) Largely rural area, pockets of deprivation (esp round hospital Y) Sustainability issues Multi-site reconfiguration Very influential local Labour MPs Y to focus on elective surgery and emergency medicine; transfer emergency surgery and trauma from Y to X; centralise acute Obs&gyn and paeds at X (move from Y) Aug 05: clinical champions; insufficient funding for full implementation; Y underused; transfers to Y stalled; significant clinician resistance; 3 hospitals still working partly independently
Trust C 2 hospitals covering remote rural area – one much larger than the other (400,000 pop, lge temp tourist pop) Geography important: smaller hospital in remote location Issues of patient safety for smaller hospital Multi-site reconfiguration No significant national political interest Cessation of 24 hour medical led emergency admissions to small hospital and development of Medical Assessment Unit working in collaboration with larger hospital Aug 05: Little service redesign implemented, negotiations continuing between conflicting stakeholders: some new roles and protocols agreed, limited joint working
Findings - 1 Class and geography: middle class dominated, smaller towns likely to produce more conflict Where reconfiguration perceived as downgrading of service provision, more active internal (professional) and external stakeholder involvement (Trusts B and C)
Findings - 2 Good consultation/stakeholder involvement doesnt necessarily lead to easier implementation (Trust B) More active stakeholder involvement means reconfiguration plans less likely to be implemented?? (Trusts B and C)
Findings - 3 Reconfiguration takes much longer and is much harder to implement than DH documents often seem to envisage Reconfiguration is a complex political process, driven by various stakeholders interests, not just or even very much a technocratic process. Stakeholder interests will play out differently in different contexts
Future of reconfiguration Patient choice and PBR) likely to result in more reconfigurations to deal with financial pressures Pressure for trusts to become FTs may mean more reconfigurations e.g. current FTs encouraged to take over trusts less likely to become FTs Local conflicts likely to increase if market allowed to work and if it destabilises providers How will potential conflicts between the policies of maintaining local service provision and those creating a market be resolved?
Who wants what? Consumer: service goals Patient: health gain goals Voter: accountability goals Popularly measured Technically measured Output Input Taxpayer: value for money goals Residents groups Local councillors Clinical professional institutes Some clinicians StHAs, some PCTs, Health economists DH?