- Providers of NHS services face a significant challenge: to deliver high quality services to meet growing patient needs, alongside continued tight funding.
- On top of this, providers of acute services face additional challenges in maintaining clinical sustainability as clinical trends shift towards 24/7 consultant led care, the concentration of specialist services on fewer sites, and the transfer of services into community settings.
- There is the potential for disruption to patient care if providers are unable to meet the growing challenges to delivering services. Monitor’s job is to protect and promote the interests of patients by ensuring that the whole sector works for their benefit. To achieve this, we are issuing a call for evidence to get a better understanding of the full extent of the challenges that acute providers face.
- The initial focus of our project is on smaller non-specialist acute providers, as our preliminary work suggests that some of these are facing particular challenges.
- Smaller acute hospital trusts are one of the main points of access to health care services for many patients. In addition to a range of elective services, these trusts provide important services such as maternity and A&E care, as well as services for frail and elderly patients who need integrated health and social care that is close to home.
- Such services can be central to meeting patients’ needs in local areas, and represent a significant amount of NHS spending. There are just over 140 nonspecialist acute trusts in England. Together these receive in the region of £50 billion per year for all their services.
- Monitor and the NHS Trust Development Authority will work together on this research project to ensure that there is alignment across our organisations. The results of the research will contribute to an evidence base around what high quality and sustainable services will look like in the future. It will inform ongoing work by Monitor and NHS England on the future of the provider landscape and the support needed to ensure that it is fit to meet the challenges that lie ahead. It also forms part of Monitor’s response to the Francis Inquiry, where we have committed to work with partners to improve our understanding of what makes NHS providers clinically sustainable.
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This is an exploratory research project to understand the factors that may influence the care delivered by smaller acute providers. We are not pre-disposed to any particular outcome or solution.
Call for evidence - The current evidence base about the challenges that smaller acute providers face is not comprehensive and would benefit from further investigation and clarification.
- For the purpose of this study, we have defined smaller providers as those with an annual income of £300 million or less. However, we would like information from acute providers of all sizes, as this will help us to determine whether smaller providers face significantly different challenges to larger ones.
- We would like evidence on:
Whether smaller non-specialist acute providers are facing particular difficulties in delivering high quality, sustainable services.
If they are, whether these smaller acute providers are facing any specific factors that:
- increase their costs (eg, providing services at small scale);
- decrease their revenue (eg, concentration of specialist services on fewer sites); and/or
- affect their ability to respond to issues and to deliver services (eg, thinner staff rotas).
The means and opportunities that smaller acute providers have to address potential challenges and to demonstrate innovative, high quality service delivery. - We are also open to evidence that factors other than scale pose challenges to providers.
- Although the study is focused on acute providers, we are keen to receive evidence from anyone interested in the services they provide. This includes patients and patient groups, all providers of NHS-funded care, general practitioners, commissioners, local authorities, health care experts, academics, and professional and representative bodies.
- We will engage widely and openly with interested parties throughout the call for evidence. In addition, we plan to send a questionnaire to all non-specialist acute hospital trusts to ask them about any challenges that they are facing. We will be contacting these providers directly but they are also welcome to respond to the call for evidence.
- We will analyse the evidence we gather and publish a report setting out the findings of our research in spring 2014.
Royal College of Physicians of Edinburgh Response to Monitor Call for evidence on smaller acute providers in England
The Royal College of Physicians of Edinburgh (the College) is pleased to respond to the call for evidence on smaller acute providers in England by Monitor. The College represents Fellows and Members across the UK, with around 50% of our UK membership working in the NHS in England.
The College is of the view that there is a need, and a future, for smaller acute units as a local resource bridging between true community services and tertiary centres. The College feels that some of the challenges faced by small acute providers include:
7/7 service
Providing a 7/7 consultant service will either entail employing more consultants or giving time off in lieu of a weekend on call, leading to weekday cover becoming stretched and gaps appearing during the normal week in elective work. A decrease in elective work could have financial implications for a small Trust.
Providing a seven day consultant service requires adequate support particularly from diagnostic imaging. Small Trusts usually manage their diagnostic imaging very efficiently but, with a 7 day service, additional costs will be incurred on additional staff, such as to run ultrasound departments or MR scanners. Review and reporting of images obtained will require greater radiologist input and small Trusts may end up sending work to be examined externally.
Specialist services
Development of specialist services is generally to be welcomed. In stroke medicine, small Trusts have combined resources to provide a 24/7 service and used telemedicine to link hospitals together. As an example, the loss of 2 physicians from a moderately sized pool of consultants in general medicine doing the acute work would be bearable. However, the system becomes unsustainable if more physicians opt out of the GIM on call rota to set up a specialist network eg GI rota. In surgery, there is the development of specialist colorectal/ vascular surgical rotas. This is having a greater impact upon general surgical on call rotas for small Trusts and we expect the same in medicine.
The viability of accident and emergency services is dependent upon adequate senior medical staff numbers. For example, if it is proposed that stroke is managed in larger units, a certain number of stroke patients will still walk into the local hospital and, once that patient arrives at their local A&E department, it is important to accurately assess the patient and initiate treatment. The problem with diversion is that the local doctor in the smaller unit may lose some skills at being able to recognise and appropriately manage these “walk in” patients and local training programmes could be compromised.
Teaching and Training
Most units, including small units, actively contribute to medical student teaching and specialist training and derive some of their funding in this way. If services are removed from smaller units, students and trainees will miss that experience and medical schools and LETBs may review the value of placements. Non-teaching units will be less attractive to skilled clinicians with an interest in training and recruitment and retention may become a challenge. Younger doctors with no experience of working in smaller units may be less inclined to apply for vacancies in such hospitals, once fully trained, adding to future recruitment problems. Smaller units, in common with larger regional hospitals, have relied on consultants working far in excess of their contracted hours, as shown in the census of the Federation of the Royal Colleges of Physicians[i]. As the demography of the medical workforce changes and more doctors seek to work less than full time, this may pose a disproportionately heavy burden on smaller units.
Current senior hospital consultants underwent training when working 70+ hours a week. New consultants appointed have been trained only in working to EWTD. It is likely that, in small units, senior medical staff have been putting in many extra hours to keep a service running safely and smoothly. Therefore, the shift from the old style trained consultant to the new consultant brought up on the EWTD will have a greater impact on small units who probably have relied on large amounts of good will to keep going.
Geography, relationship with primary care and sustainability
There is a clear need for smaller acute units, particularly in more remote parts of the UK. A large proportion of their current workload fits neither into the hyper-acute specialist tertiary services nor into community settings. Frail elderly patients in particular are ill suited to care in a regional centre located remote to their own community, but the quality of their care must not be compromised by denying them access to acute facilities with 24 hours consultant supervision.
Geography plays an important part in how small units operate. In large urban centres such as London, there are many acute units and it is possible to make strategic changes and re-organise. In contrast, a small unit which is geographically isolated and where transport in winter conditions is difficult does not have this option. Therefore any research into the future of smaller units has to consider carefully location and transport infrastructure. Telemedicine may assist but should not drive change.
To give medical staff confidence to work in more remote units, it is important that critical care cover is clear. The absence of a critical care unit that can safely and reliably ventilate patients for 24-48 hours would result in the type of unselected case that could be reliably admitted becoming very restricted, and a proportion of patients who do not need to be in an acute tertiary centre would inevitably be redirected there. It is appreciated that this creates a major resource challenge but the high standards set by the Royal College of Anaesthetists for an intensive care unit have to be preserved.
Future opportunities
A small acute provider, in addition to working in partnership with larger tertiary acute hospitals, may benefit particularly from new models of care with strong working in the community and engagement with primary care. Increased outreach to and integration with primary care could be investigated further.
As a final observation the College is mindful of the social and human effect on staff and the local community of closing services. The case must therefore be made clearly, citing the safety and sustainability problems and the need to ensure the local community benefits from hospital services that meet all recognised standards. Reconfiguration must not be seen as a solution to a failing hospital but as a way to maintain the highest quality of care for the local community.
[i] Pages 53-54, 2011 Census of the Federation of the Royal Colleges of Physicians