We want to understand why we have such extensive variation and I think if you do look at some
of the markers, you see that range of variation which is quite enormous; whether you’re
looking at mortality rates, whether you’re looking at indicators of harm for instance,
those in the lower decile, if they achieved what those in the upper decile can do, they
would be 4,000 fewer pressure ulcers reported in our hospitals every month.
Healthcare organisations, our structure organiser rooted it within this plan where the principle
of the general hospital, district general hospital providing a comprehensive set of
services to meet the needs of local population expressed to be about a size of a quarter
of a million.
We know obviously that this struggles to deliver.
When people say we shouldn’t change because it’s not in the interest of patients, we
should challenge that because often what they’re saying is that it’s not the interest of
their organisation.
My offer in this particular review is the how.
How could we arrange governance differently to deliver models of care?
What is pointed at is not a single solution, a silver bullet, one organisational form.
Indeed a number of us were fortunate to go and visit other countries, see other system
in operation and as a consequence of that, we were able to discern a number of organisational
archetypes or shapes.
I want to just reflect on a few of these very quickly.
In the bottom left-hand corner are the ones that network solutions and a new approach
of buddying, of trying to get those organisations able to show comparative success to work with
those that are in difficulty and former supported relationship.
As you move up, there are then archetypes.
Here I just want to pick one out, “joint venture,” and I will mention that there
is no acute hospital in this country at the moment that can nor will be able to deliver
the Royal College of Surgeons Standards for emergency surgery.
You simply will not be able to employ the number of surgeons required.
You could do it if you decided to serve a wider geographic base and create single-shed
services where you’re pulling your workforce, you’re taking decisions about the use of
your facilities, you may be consolidating some service but you’re creating a different
organisation where two, three or more organisations come together (I call it a joint venture)
with one governance arrangement to manage and lead that clinical service that’s provided
across a number of organisations.
So sharing risk, sharing benefit through a joint venture.
As you move up, there are other models.
We cite in the report Moorefield’s but where I’m from the Christy in Greater Manchester
practiced this model too and there are many others around the country where you have specialist
expertise vested in one organisation which they make available to others because they’ve
got the access to skills and access to facilities and equipment that they can deploy, and I
think we will see more of this as we look to find ways of providing better care at lower
cost.
As we then move up is the archetype that most people are now interest in, really doing some
excellent work in thinking about how they create integrated models of care and think
about the governance arrangements that they wrap around that.
many organisations across the country really interest in how they do this and that’s
fabulous.
And at the top right, this is a group or a chain structure where organisations see that
there is benefit in coming together and operating as a single entity with one group governance
structure wrapped around that.
We went all over the place, and looking at some of the problems and impediments at the
moment of getting change; it took a long time to get transactions done and those organisations
who have pursued them just know how laborious this can be and we came to a view that we
had simplify that and make these processes much quicker if we were to see change enacted.
I’m attracted to this notion of what I’ve called “credentialing” where those organisations
with a track record of success can, if they so choose, put themselves forward to another
assessment system building on the ones we’ve got where judgement can be made about whether
they are able to deploy what they currently do, their systems processes, methods, culture
into other organisations to spread their success.
The alternative is we can continue to spend I think an offensive amount of money on management
consultancy, on turnaround, on taking top teams out and dropping in other people.
You’ve got your choices.
We can continue as we are with the systems and the structures and the architecture that
we’ve got or we can pursue other options and get people to think through not only the
model of care that they wish to pursue and redesign that; also think through the delivery
systems and the governance arrangements that will make it happen and I hope that as a consequence,
leaders in those Boards will see themselves now as not just stewards of their organisation,
preserving the status quo but will also act to be strategic architects, to be thinking
carefully about the models of care that will deliver reliable, high quality of care for
their populations which means that governance arrangements, organisational shape and entities
most probably will need to change.
I just think this is a really exciting time for us to be in, to encourage people to think
quite differently about models of care and the way we organise to deliver those.
Thank you.