Technocracy or politics? The process of hospital reconfiguration

1. Technocracy or politics?The process of hospital reconfiguration Perri 6, Nottingham Trent University and Naomi Fulop, King’s College London

2. 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

3. What’s 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!

4. 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?) Examples of DH approved reconfiguration initiatives

5. 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

6. 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 Trust’s other hospital, continuing problems from merger, some clinical resistance

7. Trust B • Merger 3 DGHs, 2002 (570,000 pop) – hospitals X, Y and Z • New PFI’s 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

8. 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

9. 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)

10. Findings - 2 • ‘Good’ consultation/stakeholder involvement doesn’t necessarily lead to easier implementation (Trust B) • More active stakeholder involvement means reconfiguration plans less likely to be implemented?? (Trusts B and C)

11. 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

12. 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?

13. Popularly measured  Technically measured Output  Residents groups Clinical professional institutes Some clinicians Local councillors DH? StHAs, some PCTs, Health economists  Input Who wants what? Consumer: service goals Patient: health gain goals Taxpayer: value for money goals Voter: accountability goals

14. Perri.6@ntu.ac.ukNaomi.Fulop@kcl.ac.uk