Changing Care Improving Quality

7/28/2019 Changing Care Improving Quality

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Changing care, improving

qualityReframing the debate on reconfiguration


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The NHS Confederationwww.nhsconfed.org

The Academy of Medical Royal Collegeswww.aomrc.org.uk

National Voiceswww.nationalvoices.org.uk

The partners


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Foreword 2

Executive summary 4

Introduction 7

The case for change 8

Meeting patients changing needs 9Improving quality, safety and outcomes 12

Achieving better value 15

Challenges of reconfiguration 17

Getting access right 18

Getting resources right 21

Getting the system right 25

Getting leadership right 29

Getting communication right 32

Getting collaboration right 35

Conclusion 38

Participants 39

Contents


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Change is rarely easy. This is particularly truewhen dealing with an institution as complicatedand cherished as the NHS. The health service isconstantly under pressure from rising demandand limited resources, and must keep evolvingto adapt to patients' changing needs andinnovation in treatments. Challenges will alwaysemerge from this process, but we are concerned

that the debate on change has becomepolarised and is excluding those looking toengage in a more meaningful way.

Reconfiguration, the term often used todescribe large-scale changes in healthcare, hasincreasingly become associated with makingcuts and downgrading services. It is also morecommonly associated with changes to healthservices that have been triggered and drivenby a financial or clinical crisis. As such, the

act of transforming how we deliver care isregarded by many as a threat to the servicespeople rely on.

That is why we came together to produce thisreport. As national bodies, we seek to convenepatient groups, clinicians and managers fromacross the UK to move the debate on,understand what is driving change in ourhealth service and consider how we can ensureit always works in the best interest of patients.

Nobody understands the NHS better than its

Changing care, improving quality02

Foreword

patients, clinicians and managers. Every day,they witness at first hand the incredibleachievements of a healthcare system that isrecognised around the world. But they alsoobserve that historical patterns of provisionmean care is often not in the right place or atthe right time to achieve the outcomes patientswant, and there are sometimes disastrous

failures to maintain standards.

Healthcare should never be allowed to standstill. It should never be permitted to accept thatcare is not as good as it could be. If there is goodevidence from clinical research and patientexperience for changing healthcare, to improveit and deliver it in a more consistent andsustainable way, we must be at the forefront ofthe discussions of how to do so. We know therewill be concerns about the challenge and we do

not pretend that we will always agree on howhealth services should change. Cooperationrequires all of us to face up to difficultquestions about the demands we place on thesystem. We all bring our own concerns andworries to that discussion, but these anxietiesare better considered collectively, rather thanin isolation.

This report aims to highlight the value ofcollaboration and use our stakeholder

conversations to support those engaged locallyin making a decision on whether to redesignservices and, if so, how to make change happen.It provides an authoritative, expert view on acase for change that focuses on how to meetthe needs of patients, improve the quality ofcare and achieve better value for society. Thistype of change demands co-production and awhole-system approach to developing newmodels of care that treat patients in the right

Healthcare should never beallowed to stand still. It shouldnever be permitted to acceptthat care is not as good as itcould be


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prescribe how change should be delivered ata local level and nor should we. Nevertheless,we hope that the reasoned debate presentedin this report will support people to have thecourage to engage with their local healthservices and help reframe the narrative inchanging them.

Please take the time to read our report andconsider it as part of a more constructive debateon one of the biggest issues facing the NHS.

Changing care, improving quality 03

place at the right time. It is not recommendingchange for the sake of change or for services tobe redesigned without proper patient andpublic engagement.

The views have arisen from focused, structuredinterviews and a facilitated seminar withexperts in this area. Although many of our

recommendations are aimed at leaders inEngland, our message on change is relevantfor healthcare across the UK. We do not

Prof Terence StephensonChair, Academy of MedicalRoyal Colleges

Mike FarrarChief Executive,NHS Confederation

Jeremy TaylorChief Executive,National Voices


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One of the greatest challenges facing the healthservice today is the need to redesign services tomeet the needs of patients, improve the qualityof care and achieve better value for society.There is growing support among patient groups,clinicians and managers for the potentialbenefits of 'reconfiguration' in health services,which focuses on making large-scale changes to

provide care in the right place at the right time.

The Academy of Medical Royal Colleges, theNHS Confederation and National Voices havecome together to examine the case for radical,far-reaching change across the NHS. Thispartnership brings together important viewsfrom those who know the healthcare systembest, gathering evidence from over 50face-to-face interviews and a series ofworkshops and meetings.1

This report outlines what we learned from thesecrucial conversations and aims to support thoseengaged locally in making a decision onwhether to reconfigure services and, if so, howto make change happen. We have identified sixkey principles to consider as a foundation formost reconfiguration plans:

1. Healthcare is constantly changingHealth services cannot be allowed to stand stilland now, more than ever, they will need toadapt to an ageing population and theproliferation of innovative treatments.

Executive summary

2. There are significant benefits to deliveringnew models of careClear evidence on better experience andoutcomes for patients highlights that thereis more to be gained than lost in changingmany services.

3. 'Reconfiguration' is a catch-all termReconfiguration is a general term for acollection of different types of change, thedrivers of which need to be understood toconsider their potential benefits.

4. Patients can co-produce better servicesPatients and their organisations need tobe engaged as equals to critique currentprovision and redesign it to meet their needsand preferences, a practice known asco-production.

5. A 'whole-system' approach is essentialOne service cannot be changed in isolationfrom the rest of the system. New models of carewill require the health service to go beyondtraditional borders in healthcare to deliver themost public value.

6. Change requires consistency of leadershipStrong leadership is needed to developchange with the local community. Thiscollaboration relies on strong relationshipsto be formed between leaders, built on trust

and experience.

1. A full list of the participants can be found at the end of this report.


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It is clear, however, that some people aresuspicious of changes they perceive to beaimed at cutting services and downgrading thecare they receive. This is because manyattempts at change have failed up to now andhave established a toxicity to the debate onreconfiguration. This is reflected in a narrativethat tends to focus on the closure or

downgrading of hospitals, not the significantbenefits that might be gained from developingnew models of care.

The current debate on service reconfigurationneeds to be reframed, but to do so we will needto learn from where change has failed in thepast. This report offers an authoritative, expertview on the causes of these past failures. Fromthat, there are ten recommendations toconsider. Some of these are about how local

organisations can manage their plans forredesigning services and what they can do tobetter understand and respond to publicconcerns. There is also a role for governmentand national leaders to support localcommunities to redesign services in theinterest of patients.

Our recommendations forlocal leaders

1. Co-produce any change with patients don't rely on formal consultationWhere patients and their organisations areengaged from the start as equals in shaping thecase for redesigning services, it is much morelikely that reconfiguration will meet their needsand preferences and succeed in deliveringbetter experience and outcomes.

2. Create a clinically-driven case for change,to motivate clinical leadersClinical leaders bring credibility to decisionsabout health services and are motivated by adesire to improve them so they can cope withfuture challenges. Clinicians who are engagedfrom the start in shaping the clinical basis inservice redesign are more likely to take on

leadership roles.

3. Make the case for valueFinancial risks and benefits need to be openlydiscussed, along with the benefits to patientsand the public. The focus should be ondelivering 'public value' in the form of betterexperience and outcomes for patients andmore appropriate use of resources, rather thansolely on financial savings.

4. Provide a forum to consider accessAccess concerns cannot be ignored.Patients, staff and the public need theopportunity to highlight any issues they havewith the impact of changes, many of whichcan be solved by working with local authoritiesand transport groups.

5. Develop plans openly with staffStaff will understandably have concerns abouthow changing services will affect their jobs.

Rumours have a tendency to spread quicklythrough organisations. Staff need to beregularly updated with plans and offered theopportunity to input into proposals that aredeveloped openly.


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Our recommendations for nationalleaders

1. Provide more slack for changeA number of structural barriers are hinderingchange at the local level. As part of their reviewof the payment system, Monitor and NHSEngland should prioritise incentivising new

models of care and allowing commissionersthe flexibility to create investment in change.

2. Communicate a national vision oncommunity servicesCommunity care can often be unseen, causingconcerns about how it can support hospitals.National leaders need to promote coordinated,person-centred services close to home todeliver better outcomes for people with manylong-term conditions and better value for

limited resources.

3. Be clear about the rules of engagement forcrisis-driven changeReconfigurations may be driven through thefailure regime, which offers less time than isoften needed. There needs to be a clearer signfrom Monitor that change should not be pushedthrough in a crisis and that meaningful publicand other stakeholder engagement needs tobe retained.

4. Let change be driven locally and regionallyFurther reorganisations of the NHS or majorpolicy shifts will hinder the ability of localleaders to work together and buildrelationships. Continuity in leadership is akey factor to facilitate complex changes.

5. Establish a political consensus on

clinically-driven changePoliticians need to join with patient groups,clinicians and managers to highlight thepotential benefits of change, where theevidence is strong, and promote the realisedimpact it has on care.


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Service reconfiguration faces many hurdles, ofwhich semantics and language are fundamentalissues. With a myriad of different meanings andconnotations, 'reconfiguration' is understooddifferently by different people. This is reflected ina narrative focused primarily on the closure ordowngrade of hospitals, rather than on thesignificant benefits of developing new models of

care. As a result, reconfiguration is seen by manyas a threat to the services people rely on, and anattempt to rob patients, staff and the public ofsomething important. Such perceptions arecounterproductive, and many will need to beconvinced of the merits of reconfiguration so itcan deliver potential benefits.

As the voices of clinicians, managers andpatients, the Academy of Medical RoyalColleges, the NHS Confederation and National

Voices have come together to reframe thecurrent debate on service reconfiguration,bringing together important views from thosethat know the healthcare system best. Thisreport is the result of over 50 face-to-faceinterviews with patient groups, clinicians,managers, academics, statutory bodies and

Introduction

politicians conducted across the UK, and aseries of workshops and meetings tocollectively discuss healthcare. It summarisesthese discussions and presents a collectivevoice on why health services should changeand the concerns about how to make changea reality.

The three lead organisations for the project are: Academy of Medical Royal Colleges: the

independent body comprised of presidents of20 medical royal colleges and faculties thatpromotes, facilitates and, where appropriate,coordinates their work.

NHS Confederation: the independentmembership body for all organisations thatcommission and provide NHS services; theonly body that brings together and speaks on

behalf of the whole of the NHS. National Voices: the national coalition of

health and social care charities in England,which works to strengthen the voice ofpatients, service users, carers, their familiesand the voluntary organisations that workfor them.

Reconfiguration is a general term for a collectionof different types of change, often used todescribe large-scale changes in healthcare. Threetypes of change featured prominently in ourdiscussions with patient groups, clinicians,managers, academics, statutory bodies andpoliticians, and are explained in more detailthroughout this report:

moving care out of hospitals into wrap-aroundprimary and community care

centralising specialist services to concentratequality

reacting to hospital trusts that are unsustainable(the failure regime).

We use the term 'reconfiguration' fully aware thatit symbolises an unnecessarily technical languagethat has, up to now, alienated many people. Wehave tried, where possible, to speak directly. If amore constructive debate is to be had, we willneed to consider our language carefully, so thateveryone who should be part of the discussion ismotivated to do so.

We are more specific about the types of changewhen discussing the main drivers in the first halfof the report, but use the term reconfigurationmore generally as it develops to consider whysome have failed. The principles outlined in theconclusion are offered for all changes and shouldbe applied to reconfiguration as a whole.

What is reconfiguration?


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There is nothing unusual about change in theNHS. Current public spending on healthcare is118 billion, which is more than ten timesbigger than the original NHS budget in 1948.2

This growth in resources has funded atransformation in how services are delivered,often in response to the challenge of growingdemand and the development of new

technologies and methods of treatment.

Health services have therefore evolved andchanged since the inception of the NHS, as hashealthcare in other developed nations. Thisdoesn't mean change occurs naturally in theinterest of patients. In fact, it requires adeliberate decision by those in the system todirect it towards that purpose. Reconfiguration isthis deliberate decision to do things differentlyand to find alternative ways to deliver

healthcare.3 Mental health services, for example,

are unrecognisable now from those deliveredbefore large-scale changes moved more care intothe community and out of large institutions,which were generally deemed to be inappropriateplaces for many patients to be treated in.

It has been suggested that the impetus forchange in health services should come from

outside of the system, but to deliver realimprovements to patient care, change must bedriven and encouraged from within.4 We haveto recognise how to work together to devise newsolutions. This report discusses the drivers fordoing this in more detail. It highlights whatpatient groups, clinicians and managers havetold us about why health services need tochange now and how large-scale redesign canbe used to develop new models of care thatallow the right care to be delivered in the

right place.

The three drivers which were identified and will be considered in more detail:

1. Meeting patients' changing needs page 9

2. Improving quality, safety and outcomes page 12

3. Achieving better value page 15

The case for change

2. Office for National Statistics (2011) Expenditure on healthcare in the UK: 2011.

3. National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (2001) Organisational change.

4. Clayton M. Christensen (2009) The Innovators Prescription: A Disruptive Solution for Healthcare.


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1. Meeting patients' changing needs

Patients don't want to go to hospital.Reconfiguration should be about making thehealth system more convenient for them.

Patient group

There is certainly a percentage of patientsin emergency departments that could beseen in other settings. The size can beargued, the existence cannot.

Clinician

We are bound by history of where hospitalsare built. The system is not designed to workfor patients, everywhere there is a barrier.

Manager

Patients need to be at the heart of everythingthe health service does and should not fallthrough gaps in the system. People are livinglonger today and the health service has to adaptto caring for the needs of an older population,who tend to have more complex long-termconditions with multiple needs for clinicaltreatment, care and support.

Care is too often not joined up and people aretreated by teams who do not work across

disciplines. This can work well for patients withconditions that are relatively easy to diagnoseand treat, but is more difficult for those withlonger term conditions. Services for the latter

can be difficult to navigate, as they need tomanage their health over time and require awider range of services.

We were told that many patients findthemselves being shunted around the system,and that it would be better if more services weredesigned and organised around their needs.

Reconfiguration will need to focus ondeveloping new models of care that are able toprovide packages of care closer to home. Thecurrent tendency can be to push patients intohospitals by default, whereas they need accessto the right treatment in the appropriate settingfor their condition. This is not to suggest thatolder people are not safe in hospitals, butinstead that some conditions could be treatedoutside with more convenience and dignity and potentially with better outcomes.

Urgent and emergency care is the point wherethe pressure to deliver appropriate care is mostintensely felt. The NHS has experienced aphenomenal growth in unscheduled care overthe past decade. This is raising seriousquestions about the capacity to maintainquality standards.5 We heard that some peoplewere being treated in the emergencydepartments of hospitals with conditions thatmight be treated effectively in the community.

The percentage of people attending emergencydepartments with these conditions will varybased on a number of factors, but researchindicates that between 10 and 30 per cent ofemergency department cases could be classifiedas primary care cases, i.e. types that areregularly seen in general practice.6

5. Appleby, John (2013) Are accident and emergencyattendances increasing? on King's Fund blog(29/04/13).

6. Primary Care Foundation (2010) Primary Care andEmergency Departments.

Reconfiguration will needto focus on developing newmodels of care that are able to

provide packages of care closerto home


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The emergency front door is not the onlypressure point though. We were also told aboutthe need to consider how patients in hospitalscould be discharged more promptly, withsupport from recovery and continuing carecloser to home.

Care pathways therefore need to be developed

to establish a bigger role for services outside ofthe hospital, so they can deliver more care inthe community and bridge gaps between caresettings. Primary care can deliver many ofthese services, but it is also under pressurebecause of increasing demand. Communityservices are also usually better located, butwill need more investment to develop theirrole. More investment will also be neededto better integrate social care services,particularly given the impact that unmet

social care needs have on physical health.The capability of primary, community andsocial care needs to be developed to providea wrap-around, coordinated service. This willbe part of reducing the numbers of peoplewho are in hospitals unnecessarily. There isalso an opportunity for hospitals to delivermore of their services directly in the community

and have physicians working beyond thehospital walls with colleagues in primary andsocial care.

Better coordination of care along these linescould create a framework to enable moreperson-centred care, although it wouldn'tnecessarily guarantee it. Providers across the

system will need to come together to show theycan deliver a continuum of care for patients,who could also be supported to manage theirconditions as successfully as possible. Properlycoordinated, person-centred services offer anopportunity to deliver better care for the healthand wellbeing of people, rather than simplydealing with the sickness of patients whenthey arrive at a hospital. The system-widecommitment by the National Collaborationfor Integrated Care and Support highlights

this common purpose and is an example ofco-production between patients, service users,their organisations and system leaders.7

7. National Collaboration for Integrated Care and Support(2013)Integrated Care and Support: Our SharedCommitment.


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2. Improving quality, safety andoutcomes

Too many people are seeing too few people,like the super-specialists that look at justone organ.

Clinician

There needs to be more openness withthe public about how erratic their servicesare. Many people don't know how muchvariation there is during the week andassume all is fine.

Manager

The case for concentrating specialistservices has been over-claimed, the datais not as clear cut, which makes it harderto get on board.

Paul Burstow MP

The development of healthcare treatments overthe last few decades has been remarkable.Medicine and nursing have both become morespecialised and disease and organ-basedspecialities have grown rapidly. Treatments arenow more effective and play a big part in theincrease in survival rates for single conditions.

The clinicians we spoke to highlighted thathighly-specialised care does, however, presentchallenges. Fewer units are able to delivertreatments as they become more specialised. Thisis because there is a smaller pool of adequately-trained staff available and the technology theyneed is often more high-tech and expensive.

A succession of royal college reports havehighlighted strong consensus and compellingevidence for the need to concentrate various

specialist services into fewer centres (see box onpage 14). These central settings would allowmulti-disciplined teams to be assembled to

provide adequate medical cover and a betterenvironment to develop clinical skills andexperience. Managers told us that theseworkforce concerns were a significant reasonwhy they considered reconfiguration essential,indicating that they did not have the scale andscope of practice or the workforce pattern todeliver safe services over and over again.

Managers also highlighted that it is difficult todeliver specialist services consistently throughoutthe whole week, primarily because currentpractices and workforce rotas do not allow for it.Both clinicians and managers suggested that aconcentration of specialist services would providethem with the opportunity to be more flexiblewith rotas and increase the scope to deliverseven-day care with consultants always available.Considerable feedback highlighted that the

variation in service quality from one day to thenext was not yet fully recognised by the publicand that greater awareness would likely intensifythe need for change.

It is important for patients that theserecommendations are explored and considered.Evidence from national clinical audits andregistries supports clinicians in making the casefor establishing larger centres of excellence toimprove outcomes for many specialist services.10

The evidence, however, is not clear for servicesin all parts of the UK, and internationalanalysis also suggests that the relationshipbetween volume and outcome might not beas strong for all specialist services.11 Our

10. Royal College of Surgeons (2013) Reshaping surgicalservices.

11. Harrison, Anthony (2012) Assessing the relationship

between volume and outcome in hospital services:implications for service centralization in Health ServicesManagement Research (Volume 25, Number 1)


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conversations indicated that it was sometimesdifficult to translate the evidence forcentralising services on a national level to localservices and circumstances. This can makereconfiguration more complicated. If theevidence is clear, it is difficult for anyone tooppose it. But if it is based on a 'leap of faith',it will be harder to obtain agreement on what

that judgement is based on. This was a majorconcern for many people, particularly thosereliant on experts to agree on how servicesshould change.

We generally accept that judgement plays animportant part in the delivery of healthcare andso it should do when it comes to consideringhow to deliver services. The fact that the

evidence for some reconfigurations is based oninterpretation should not necessarilyundermine the case for change, so long as those

judgements are formed by people who know theservices best. They can examine the risks andconsider how they balance against the risks ofno change.

Those who know the services best include thepatients who use them and patientorganisations with accumulated experience andexpertise. Where patients and patient groupshave been able to see clear evidence of the needto improve quality and safety through servicechange, they have supported the rationalisationof specialist services as in the London StrokeStrategy (see case study below).

The London Stroke Strategy replaced 32 strokeunits across the capital with eight hyper-acutestroke units (HASUs) as the first destination foranyone who has a stroke in the capital. After aninitial 72 hours of specialist care, patients aretransferred to their local hospital specialiststroke unit. Quality criteria apply to all of thestroke units in London, with the HASUs havingto meet specific quality standards associated

with delivering 24-hour emergency stroke care.

The model did require extra investment, butthat investment has resulted in a reduction inoverall costs across London as the averagelength of time patients stay in hospital hasdecreased. Early findings show impressiveimprovements in stroke care across the city,

with an increase in the use of thrombolysis to arate higher than any other major centre in theworld and an overall fall in mortality rates acrossthe capital.12

Before 2010, stroke care in London was veryvariable, with some of the best stroke treatmentin the world available from central Londonhospitals, and relatively poor care in many parts

of outer London. There was initially someresistance to the London stroke model, butclinicians and patient organisations were unitedin believing that reconfiguration was needed. Itis clear that it is delivering high-quality strokecare to all Londoners; the clinical case has reallybeen proved.

Joe Korner, Stroke Association

Case study: Improving quality, safety and outcomes in stroke care

.12. Royal College of Physicians (2010) National Sentinel Stroke Audit 2010.


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Royal college reports

TheCollegeisadamantthat the obstetricdeliverysuite

needsfullyqualifiedspecialists

availableatall times,24hoursa day,7 days aweekm

orethanhalfofallbirths,afterall,take

place'outofhours.Thatrequirestheemployment ofm

ore specialists, which raisesthe issue

ofaffordability.This,inturn,maywellmean feweracut

eobstetricunits,sothatforthemore

specialisedobstetric care,womenmayhavetotravel fur

therastheserviceappliesthelogic

thatcareshouldbe'localised whereposs

ible, centralisedwherenecessary.

RoyalCollegeofObstetriciansandGynaecologists

13

Transforming the care that patients receive can only be achieved by challenging existingpractice. Organisations involved in health and social care, including governments, employersand medical royal colleges, must be prepared to make difficult decisions and implementradical change where this will improve care.

Royal College of Physicians London14

Whilstfulladoptionofthestandards[onsev

endayconsultantpresentcare]maydeliver

somesavingsovertime,itisnotanticipatedthattheywi

llbeself-funding.Otherinterventions,

suchaschangesinworkpatternsandservicereconfigurationontofewersites,willben

eeded.

AcademyofMedicalRoyalColleges

15

The demands placed upon the NHS in terms of changing patient needs and expectations,increased specialisation, the availability of new treatments and technologies, and thechallenging financial environment, mean that in many cases maintaining the 'status quo' will notbe an option. The NHS must demonstrate that it can deliver safe and effective care to patients,while ensuring the efficient use of taxpayers' money.

Royal College of Surgeons of England16

TheCollegewillworkfurther

toencourageunitstoprovid

ebetterconsultant(orequivalent)

coveragewhentheyareatthe

irbusiest.Itisessentialthat

paediatricsisa24hoursad

ay,

sevendaysaweekspecialty,

andconsequentlytheservice

shouldbeorganisedaround

the

childsneeds.

RoyalCollegeofPaediatricsa

ndChildHealth17

13. Royal College of Obstetricians and Gynaecologists (2012) Tomorrows Specialist.

14. Royal College of Physicians (2012) Hospitals on the edge?

15. Academy of Medical Royal Colleges (2012) Seven Day Consultant Present Care.

16. Royal College of Surgeons of England (2013) Reshaping surgical services.

17. Royal College of Paediatrics and Child Health (2013) Back to Facing the Future.


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3. Achieving better value

The economic ability to fund currentmodels of care has been great, but thechanging economic environment hasquestioned this. Reconfiguration wasdifficult before the pressures hit, but nowthere is no alternative.

Manager

It is difficult for us to think this way but,within a limited budget, profligacy in thetreatment of one patient comes at theexpense of treating another.

Clinician

The NHS seems to have focused more oncuts before reinvestment.

Patient group

The health system operates with finiteresources and funding is directed to it fromtaxpayers. It is important therefore that thevalue from the money spent is maximised todeliver the greatest benefit to society. The needto spend money well has never been moreimportant than in the present financialenvironment. If services need to change, it can

no longer be done on the basis of annualbudget increases.18 The NHS in England isgoing through its tightest financial squeezefor 50 years and economists believe it ishighly unlikely there will be increases in linewith the historic average. This could mean thata gap of up to 54 billion will need to be filledby 2022.19 If health funding is unlikely to

increase, alternative ways will need to befound to pay for the shortfall. This will focusmainly on making the most of resources thatare currently in the system and ensuring theyare spent in a way that delivers the mostpossible public value.

Public value means not just value for money

but the overall sum of benefits, which includesbetter experience for service users, betteroutcomes, and the most appropriate use ofresources. Resources are more than just money.Staff, estates, technology, patients and theircarers are all resources the health systemregularly draws upon, and it should be lookingto capture the greatest possible value from allof them.

This means considering the value that patients

and service users themselves can bring, forexample by using their experience to helpco-design more successful and appropriateservices, and by successfully managing theirconditions, with the right support. Evidencefrom hundreds of research studies shows thatpatients who are more involved in their healthand healthcare are likely to report a betterexperience and better outcomes. They are alsomore likely to make the most appropriate use ofservices, for example by taking up preventive

services and by opting for less interventionisttreatment.20

It also means looking at where we currentlyput many of our resources and decidingwhether they might be better spent elsewhere.If resources are being spent to maintain thecurrent models of care, but there is more to

18. NHS Confederation (2013) Tough Times, Tough Choices.

19. Nuffield Trust (2012)A decade of austerity?

20. Coulter, A and Ellins, J (2006) The effectiveness of patient-focused interventions.


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This project aims to reframe the current debateon service reconfiguration so it can focus moreon how to meet patients' needs, improve thequality of care and achieve better value. Patientgroups, clinicians and managers are clear thatnew models of care need to be considered. Butthis is not a new conversation. Models of carethat treat patients outside of the hospital have

been developing, but are progressing slowly andactivity continues to be directed through thehospital. The prevailing focus has been on tryingto make hospitals as efficient as possible bydecreasing average length of stay and hospitalbed numbers.22

Reconfiguration, however, should be aboutmaking larger scale changes across the system

to deliver more appropriate care for patients.There have been many attempts at this, but thesuccess has been mixed. We cannot avoid thefact that despite good drivers for change, manyattempts have failed up to now to deliver thepotential benefits. We discussed with expertsthe reasons why many changes had failed andsix factors emerged as crucial to success.

For each, three primary concerns werehighlighted, which will need to be addressed toprogress the reconfiguration debate. We alsooffer case studies and tips that might supportthose engaged locally and nationally in dealingwith these concerns and will help to sharelearning about what has and has not workedelsewhere.

22. Appleby, John (2013) Feature: The hospital bed: on its way out? in British Medical Journal (12/03/03).

Challenges of reconfiguration

Six factors crucial to success

1. Access page 18

2. Resources page 21

3. The system page 25

4. Leadership page 29

5. Communication page 32

6. Collaboration page 35


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Getting access right

Patients will travel to the ends of the worldfor the best treatment, but will be annoyed ifthey have to travel far for routine checks.

Patient group

Patients need to know that distanceis not always a major factor. It needsto be explained that current services canmean that it actually takes longer to betreated because you need to be referred onagain.

Clinician

We need to work out how to offer a visionfor community care. At present, we haven'tbeen able to articulate effectively what

community care is, other than presenting itas the opposite to hospitals.

Clinician

If specialist services are concentrated intofewer central sites, some people will need totravel further for treatment. A YouGov surveywith the Welsh NHS Confederation highlightsthat more than three-quarters of respondentswould be willing to travel further for treatmentto see a doctor who is a specialist in their

field.23 This would suggest that people couldbe convinced to support services beingmoved further away if it meant they couldreceive better quality treatments. Patientgroups told us that: Patients are likely tomeasure access more broadly than simplytime and distance to their local hospital.Instead, good access for them will relate to

the right care for their condition, regardless ofwhere it is delivered.

This is not to say that time and distance arenever important factors. A study into severetrauma suggests that there may be a 1 percent absolute increase in mortality forlife-threatening conditions with each extra tenkilometres in straight-line distance.24 Clinicianstold us that the impact of distance on outcomes

should never be disregarded, but this didn'tmean that the distance between the hospitaland the patient could never be increased safely.If clinical risks are better understood, peoplewill see that they are often minimal whencompared to the potential benefits of thechange. This means communicating exactlyhow the most serious conditions will behandled, for example by showcasing anassortment of 'what if' scenarios to highlighthow quickly different patients will be able to

access services.

Clearly, there is a difference between accessissues in urban and rural communities, withconcerns about access for urban servicestending to centre on timescales and distancesthat are much smaller. We were told that urbancommunities were often concerned by the

If clinical risks are betterunderstood, people will see thatthey are often minimal whencompared to the potentialbenefits of the change

23. YouGov (2011) YouGov /Welsh NHS Confederation Survey Results.

24. Nicholl, Jon et al (2007) The relationship between distance to hospital and patient mortality in emergencies: anobservational study in Emergency Medicine Journal (22/05/07).


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impact of traffic on access, while for many ruralcommunities the main issue was the availabilityof public transport and adequate travel routes.This highlights the importance of having a goodunderstanding of the specific local needs andconcerns with regards to access.

There is no universal resolution to the issue of

access in reconfiguration. Local communitiesneed to be engaged in a discussion about thedifficulties in moving services, and people needthe opportunity to feed back their concerns andhelp to resolve them. We were told that manysolutions to individual access concerns could beidentified by working with local authorities andtransport groups, rather than changing plansthemselves. A dedicated access forum therefore

offers a good way of understanding issues thatlocal people might have and allows them to beexplored in more depth with local partners.

Some concerns about access relate to thefeeling that community services do not have thecapacity to deliver the care currently delivered inhospitals. One clinician told us that people go

where the lights are on, and it is understandablethat they would see hospitals as the best placefor treatment because that is where manyresources are spent. If awareness of communityservices is low, people are likely to be lessenthusiastic about a new model of care thatmoves care to them. More is needed toemphasise the care that can be provided in thecommunity and highlight how it can deliver the

We didnt have to think shall we gooff and talk to the mental health trust

about their elements of dementia andto the trust about the community.We could all have that information aspart of the discussion. It made our wayof working a lot quicker.HWB member

Better Healthcare in Bucks was a publicconsultation that sought to relocate acuteservices and integrate community servicesacross Buckinghamshire. Discussions withpatients showed support for a model of caredelivered closer to home and an understandingthat consolidation of acute specialties mightincrease travel times for those admitted tohospital. A recurrent theme for patients and the

public was transport. Parts of Buckinghamshireare poorly served by public transport and thisadded to natural concerns about getting to andmoving between sites.

In response to this, a transport group wasestablished made up of council, hospital andambulance service representatives, whichlooked at the issues in more depth and evenheld its own engagement sessions. Outcomes

from this group were improved and free travelon local bus networks, and the establishment ofa county-wide community transport hub toprovide a central information point forcommunity and voluntary transport.25

We understood from the start that we wouldnever be able to provide a door-to-door service toeveryone, but in reality the local community

didn't expect us to do so. What they wanted us todo were the obvious things. By working withlocal partners, in a total place way, we were ableto arrange for free travel for staff, patients andtheir extended family between our hospital sites.Our community transport hub also bringstogether a network of volunteer providers andhelps to support them in delivering animportant transport service to patients.

Ian Garlington, Buckinghamshire Healthcare NHS trust

Case study: A dedicated transport group to consider access

25. For more information, see NHS Confederation (2013) Service redesign case study: Better Healthcare in Bucks.


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as part of new models of care. Some people toldus that telehealth could offer many benefits topatients, allowing them to be treated in theirown home and to be empowered to takecontrol over their own condition. It is clear,however, that the evidence for telehealth stillneeds to develop and that it cannot bepresented as an easy solution to issues of

access. If technology is integrated into newmodels of care, it should be able to provide animportant part of the continuum of care andhelp to improve the communication betweenservices that are working together around theneeds of patients.

same if not better outcomes for manyconditions compared to the hospital. We weretold that community services were often unseenand that a distinct vision was needed tocommunicate what they can offer patients inpractice. Experience of the services will beimportant to do this, but where there is lessfamiliarity, it could be useful to publish a

collection of local patient stories that drawattention to the experiences of those that haveused them.

This vision could also establish a bigger role fortechnology and explore the value it might offer

People may find it harder to access care when services are concentrated onto fewer sites

Some people will need to travel further for specialist care, but the treatments they receive should bebetter quality. Patients should also benefit from having good access to more convenient care deliveredby a blend of local services. Where there are access concerns, a specific group that explores concernsin detail with local partners, such as the local authority and transport groups, can resolve issues thatare raised by staff, patients and the public.

The public are concerned that bigger distances to hospitals will have a negative impact onclinical outcomesLonger access times can pose clinical risks that are often small when compared to the benefits frommoving services. Many risks sit with the most serious conditions, but these are less frequent and canbe reduced by good contingency planning. It is important that clinicians are engaged from the start

to help make this judgement. It is important to develop a plan that considers how the most seriousconditions will be handled and to use this when highlighting to patients and the public that changeswill not compromise clinical outcomes.

Many people are not certain that community care can replace the services currently deliveredin hospitalsThe public are more likely to support moving care out of hospitals if they are aware of the benefits ofcommunity care. Local leaders need to offer a vision for community services that highlights how theycan deliver the same, if not better, outcomes for many conditions compared to the hospital. Thismessage could be delivered locally through patient stories that showcase what community care canoffer. To support a local vision for community care, national leaders need to offer a unified messageon the value of care delivered as locally as possible.

Primary concerns about access


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Getting resources right

There should be a fifth Lansley principle,a hurdle test which requires advocatesfor acute reconfigurations to set outcosted plans for developing primary andout-of-hospital care. Without such plans,the public is being invited to take a leap inthe dark.

Paul Burstow MP

The timescales and resources on hand forreconfiguration can make you feel like you'reknitting fog.

Manager

There is an obstacle of time. Hit squadssolving the problem in minimal time will

not help, they will just present plans as afait accompli.

Clinician

There is no blank sheet of paper on whichhealth services can be designed. Currentmodels of care are treating patients now and itis difficult to shift resources to invest in newmodels without potentially impacting on theservices patients currently need. Changing

services can therefore be like fixing an enginewhile the motor is still running. If thedisinvestment in services is more visible thanthe money going back into developing newmodels of care, people will perceive it simply asa cost-cutting exercise.

Our conversations highlighted that manyattempts to shift resources had hitherto fallenshort in making clear the reinvestment into newmodels ofcare. Ideally, this perception could be

countered by establishing a period of timewhere current services continue to be funded

Changing services can thereforebe like fixing an engine while themotor is still running

in parallel with the investment into new models

of care. This phase of double-running helpspatients to migrate gradually from one serviceto the other, or else carefully manages thedisinvestment in current services. We were toldthat this would soften many transition risks andcould help people to recognise over time thebenefits of investing in community care. Theobvious problem is the costs associated withfunding multiple services simultaneously,which for many local health economies willbe an unmanageable challenge. This is

compounded by the fact that the process itselfis resource-intensive anyway.

It is apparent therefore that new models of careare limited by the resources that are available todeliver them, which in a no-growth healthfunding scenario will be especially scarce. One ofthe main challenges is often not how servicesshould be changed, but how the whole processwill be funded. We were told that the hopes forsavings being made early in the process to fund

investment were often unrealised, which made itnecessary for funds to be available up front.However, we did hear that it was sometimespossible to save costs in the short term, but that itdepended greatly on the services being changed.

Reconfiguration should be based on ajudgement that care will improve over time, butit can often be triggered by a concern about thesustainability of current services. Finance andquality are intrinsically linked and the ability to

disinvest from services that need to change willbe limited, without impacting on the quality of


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services in the transition. Aside from externalinvestment, there doesn't appear yet to be aneasy solution to this challenge. It is importantthough that new models of care are delivered onthe basis of realistic objectives for financialinvestment, both in the short and long term, sothat it is clear from the outset how much it willlikely cost. It will also need to be realistic and

clear about how the clinical benefits will bemeasured, using transparent data that can beset out in advance and tracked throughimplementation.

If resources are limited in general, they areespecially restricted when a change is beingdriven by crisis and has been brought about byfinancial instability. It is becoming increasinglyapparent that many trusts are being pushedcloser to a financial cliff edge, which will raise

serious questions about the way services aredelivered. The new NHS failure regime in Englandgives a trust special administrator (TSA) 150 daysto secure the continued provision of NHS servicesfor trusts that are no longer a going concern.From our conversations, it was clear that thissmall window would offer little opportunity todevelop plans with the local community,particularly considering that existing forms ofengagement are explicitly cut off with thedissolution of the trust's board and the removal

of governors. Monitor's guidance to TSAshighlights the difficulty in gaining support fromcommissioners and other local providers for anychanges that raises public concerns, but itsrecommendations for engaging with patients,staff and the public focuses too much on needingto reassure and inform them.26 Financial failure

cannot justify the exclusion of the localcommunity from shaping health services.

Monitor's current guidance to TSAs states thatthey must consult with NHS England and allcommissioners when drafting their report, butthat they should use their judgement onwhether to engage staff and the public. This

needs to be urgently reviewed. It should bemade clear that it would be exceptional forstaff and the public not to be engaged, at leastinformally, in the drafting of proposals by theTSA and that, where they deem thisunnecessary, the reasons why should be madeclear. Excluding the public from coproducingchange in the failure regime guarantees thatit will be set up to dissatisfy the localcommunity, and will likely deliver a changethat they cannot be sure will be in the interests

of patients.

The failure regime is a new concept for theNHS, but it is inevitable that health serviceswill be changed through it in the future.These changes will be reactive to immediatefinancial concerns and we cannot ignore thedifference between this and the type ofproactive change this report is primarilylooking to encourage. This is not leastbecause the former will be restricted both by

time and resources, while the latter will havegreater scope and capacity to deliver change.The commissioning system has anincreasingly urgent challenge to get aheadof this curve, planning proactive change, soas to avert crisis-driven change beingimposed later.

26. Monitor (2013) Statutory guidance for Trust Special Administrators appointed to NHS foundation trusts.


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We didnt have to think shall we gooff and talk to the mental health trustabout their elements of dementia andto the trust about the community.We could all have that information aspart of the discussion. It made our wayof working a lot quicker.HWB member

Last year, South London Healthcare became thefirst NHS trust to enter administration and besubject to a new failure regime. The trust hadconsistently struggled to provide services withinbudget and there was no approved plan to fix itsproblems in the long term. A trust special

administrator (TSA) was appointed by theSecretary of State, and his final report outlinedrecommendations for securing sustainableservices for the local community.27

The report made a number of recommendationsas to how services should change, including aproposal to replace the full admitting accidentand emergency department at UniversityHospital Lewisham, which was not part ofthe trust, with a non-admitting urgent care

centre. In the report, the TSA said: Thisrecommendation is not about 'closing' an A&Edepartment but rather making changes to it. Ifyou can get yourself to the hospital in a car or onpublic transport then University Hospital

Lewisham's Urgent Care Centre would be able togive you the care you need.28

A campaign was formed to oppose the changesto University Hospital Lewisham, and thousandsof people took part in a series of protest

marches both during and after the consultationperiod. A particular criticism by the campaignwas the decision to include a hospital in thechanges that was not part of the trust inadministration. Ultimately, the Secretary ofState approved the proposals, but decided thatUniversity Hospital Lewisham should insteadretain a smaller A&E service with 24/7 senioremergency medical cover.29

South London was intended to be the process

that would set a precedent for reconfigurationand pave the way for future attempts. It turnsout to be the exact opposite, as it has set aprecedent for preventing future attempts.

Manager

Case study: Crisis-driven change

27. South London Healthcare NHS Trust put into administration, BBC News (12/07/12).

28. Office of the Trust Special Administrator (2013) Securing sustainable NHS services.

29. Protest against plans to scrap Lewisham Hospitals A&E, Daily Telegraph (26/01/13).


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The public see the money coming out of services, but are not always aware of the money going back inPeople will not be enthusiastic about services being changed if they cannot see the investment intonew models of care and the services that are needed to deliver them. Reconfiguration needs to sell thebenefits rather than the cuts. The best way to show investment is often to run services alongside oneanother and gradually migrate patients from one model to another. However, this can make theprocess even more expensive and will require extra investment to be available from the start. Local

leaders need to ensure that they are clear about the level of investment needed and to identifywhere it will come from. National leaders need also to consider whether there is capacity to deliverlarge-scale change across the healthcare system.

Changes don't seem to save money and often appear to cost moreThe need for change is focused on improving quality and ensuring sustainability in the long term andso it cannot be expected to save money immediately. Better quality services should save money overtime or else they will capture greater public value from the resources available. Local leaders shouldmake sure they have realistic plans on costs and that they set achievable targets that help to maintainmomentum during implementation.

The NHS failure regime offers too small a window for engagement with the local communityFinancial failure will drive more change through the NHS failure regime, which regulates a settimetable to develop plans. This timetable provides a small window for co-production, but it shouldn'tbe used to justify the exclusion of the local community from shaping health services. The role of thelocal community needs to be clearer during the failure regime. Monitor should recommend morestrongly to the trust special administrator that they engage with staff, public and patients as theydevelop their report. Monitor also needs to observe how the failure regime is proceeding and look toreview its flexibility and capacity.

Primary concerns about resources


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Flexibility in the reimbursementof services is important to allowthe risks and benefits frommoving care to be shared fairlyamong providers at the locallevel

Getting the system right

Society can often be averse to changingthe status quo, but we need to convinceeveryone in the system when the status quoneeds fixing and why.

Clinician

There is a price disincentive to keep servicesin the acute sector. If moved, variable costswill fall but they have fixed costs that need tobe utilised. The result is that patients aresucked into their services.

Patient group

Pricing won't help you find win-wins. Tariffdoesn't usually allow change and cannotfacilitate benefit sharing. There doesn't

seem to be any slack for reconfiguration atthe moment.

Manager

The NHS payment system in England relies to alarge degree on reimbursing hospital care on thebasis of activity, which can incentivise hospitalproviders to deliver more treatments to covercosts that are often fixed. Primary andcommunity care on the other hand tend to bereimbursed in blocks that can create incentives

to deliver less to minimise costs. If new modelsof care are to develop that utilise servicesoutside of hospitals, financial incentives willneed to be aligned towards this objective.Otherwise, change will be more difficult and lesssustainable for some providers. Flexibility in thereimbursement of services is important to allowthe risks and benefits from moving care to beshared fairly among providers at the local level.

Monitor and NHS England recently outlinedtheir current reasoning for the objectives ofthe NHS payment system, which they willgovern together from 2014. They made it clearthat services need to be redesigned to offerimproved patient outcomes at lower costsand that the design of the NHS paymentsystem should support both commissioners

and providers in making the change that NHScare needs. This would support what we heardfrom patient groups, clinicians and managers,and it is important for this to remain as oneof the primary objectives for the paymentsystem.30

Our discussions also identified questions aboutthe impact of competition in healthcare. If thenumber of hospitals is reduced this couldunfairly restrict patient choice, and could raise

concerns with regulators looking to preventany substantial lessening of competition.31

Competition and integration shouldn't bemutually exclusive, but commissioners willneed to ensure that collaboration is nothindered by providers needing to compete forservices. Monitor will advise the Office of FairTrading about the patient benefits of anyproposed mergers involving NHS foundation

30. Monitor and NHS England (2013) How can the NHS payment system do more for patients?

31. Competition Commission (2013) CC to investigate hospitals merger (08/01/13).


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trusts.32 In doing so, it will need to ensure thatcompetition can be used to drive up quality, butthat it fulfils its obligation to enable integratedcare and encourage providers to work together.

We were also told about several other legal andregulatory requirements that need to beconsidered, including an obligation to consult

with the local health overview and scrutinycommittee (HOSC) on proposals for substantialchanges in local health services.33 Managerstold us that there was generally good availableguidance for many of these obligations, but thatstrong project management was important tokeep on top of them all.34 They also stressed thevalue of developing strong relationships withrelevant bodies throughout the process to helpdeal with uncertainties. One of the main riskspresented to us was the potential loss of

momentum, if changes are stalled at a laterstage by legal review.

NHS England is currently reviewing the role oflocal HOSCs in scrutinising changes to servicesand it will need to do this with considerationof the new role of local health and wellbeingboards (HWBs). We were told that theseboards could offer an opportunity to providegood strategic direction for local servicesand a degree of democratic accountability

that can often be lacking. The guidance whichwill follow that review should be clear aboutthese roles in service change and be reflective ofthe need both to ensure proper scrutiny and to

maintain the momentum built up throughengagement and consultation.

NHS England's review will also need to supportlocal leaders in understanding the shiftinginfluence within local communities, followingrecent reforms. Clearly, newly-formed clinicalcommissioning groups (CCGs) will have

significant responsibility for driving new modelsof care and it is important that they have thesupport and guidance to help them to do that.NHS England is developing the role of new NHScommissioning support units (CSUs), so theycan support CCGs in their transformationalcommissioning functions, such as serviceredesign.35 Similarly, clinical senates, which willspan professions and include representatives ofpatients, volunteers and other groups, are beingdeveloped to have a proactive role in promoting

and overseeing major service change, forexample advising on the complex andchallenging issues that may arise within theirareas.36 Local area teams of NHS England willplay a role on HWBs and will directlycommission primary care locally.

Added to these new structures is the need toencourage an open culture that allowsrelationships in the community to develop. Ourdiscussions highlighted that consistency was

crucial to allow leaders to work together andthat this would be less likely if the systemcontinued to reorganise and changed leadersregularly. Even at a lower level, there was

32. Monitor (2013) The respective roles of Monitor, the Office of Fair Trading and the Competition Commission in relation tomergers involving NHS trusts and NHS foundation trusts.

33. Mason, David (2012) Public involvement and consultation in Capsticks CCG Handbook.

34. Useful resources can be found on the NHS Confederation website: www.nhsconfed.org/reconfiguration

35. NHS England (2012) Commissioning support: Key facts.

36. NHS England (2013) The Way Forward: Clinical Senates.


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emphasis on the importance of maintainingstaff who have experience of joint working andservice change. The system needs to have anopen culture that supports innovation. Weheard of few incentives for leaders to be boldand take risks. Instead, many often fear that

such actions will be punished or else gounnoticed. Many people suggested that this haddrained the enthusiasm in the system and thatchange fatigue was apparent, which made itharder to work together and maintainmomentum for change.

We didnt have to think shall we gooff and talk to the mental health trustabout their elements of dementia andto the trust about the community.We could all have that information aspart of the discussion. It made our wayof working a lot quicker.HWB member

Southern Health NHS Foundation Trustsuccessfully acquired Oxfordshire LearningDisabilities NHS Trust (also known as theRidgeway Partnership) in November 2012. Theprogramme team described the process as likebecoming a foundation trust all over again,with a team of staff undertaking engagementand compliance work in order to meet financial,governance and strategic criteria for the merger.This work began early, even before the trust hadbeen designated as the preferred provider,aware of the risk that it would be wasted if theywere not chosen as the preferred provider. Theteam developed good relationships with localstakeholders, including families and carers, andgave regular updates about the proposals,including through open door events.

Eventually, the trust was designated as the

preferred provider in March 2012, but variouslegal and regulatory hurdles meant that theacquisition was not completed until November2012. This proved a significant challenge andthere was a big risk that the momentum thathad been built during the engagement process

would be lost. The trust continued to engageand communicate the benefits of the change,but as time developed some patients and staffgrew concerned that the change would not nowtake place. To allay concerns, and being mindfulof the fact that many of the patients theyneeded to engage had learning difficulties, theyattempted to communicate each legal andregulatory hurdle as a gate that had be openedand used them positively to highlight wheretheir plans had gain independent approval. Thisstrategy needed to flex as the dates for thevarious approvals regularly changed, but theteam worked extensively to maintain a highlevel of patient, carer and stakeholderengagement.37

At first, all the effort we put intocommunicating the legal and regulatory hurdlesfelt like overkill, but in the end it was veryworthwhile. The delay in getting the finalapproval was frustrating, but we tried to useeach individual step in the process as a positivesign that we were progressing.

Southern Health NHS Foundation Trust

Case study: Dealing with systemic challenges

37. NHS Confederation (2013) System redesign case study: Southern Health acquisition of Ridgeway .


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The current pricing system is creating a disincentive to develop new models of careFinancial incentives that encourage activity in hospitals will not support new models of care that lookto deliver more care in the community. Local leaders need to explore what flexibilities there are in thecurrent payment system to try to support reconfiguration. NHS England and Monitor should designthe NHS payment system to support both commissioners and providers in aligning incentivestowards the objective of delivering more appropriate care.

Legal and regulatory hurdles can stall change and make it lose momentumThere needs to be good local scrutiny for changes to health services. Local leaders need to ensurethat they are prepared for the hurdles currently in the system and to develop strong relations withthe relevant bodies. NHS England needs to use its review of reconfiguration to clarify roles andresponsibilities in the system and offer support to commissioners in driving change. In doing so, itwill need to be reflective of the need both to ensure proper scrutiny and to maintain the momentumbuilt up through engagement and consultation.

Risk-aversion and change fatigue is apparentThe culture in the NHS needs to be open to local leaders taking risks to challenge the status quo in

healthcare. All local leaders will have a role in trying to establish this culture and to build up theenthusiasm for change. However, national leaders will need to recognise the need for a period ofstability and be alert to the dangers of reorganising the system further.

Primary concerns about the system


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Getting leadership right

We need to find a way to make cliniciansmore visible to win the trust of the localcommunity.

Patient group

There will be disputes between clinicians,but this can be good if it is evidence-based.

Clinician

Change needs a consistent and persistentvision in the long-term. We need to do moreto retain corporate memory because withoutconsistency you forget what works. Thiscannot be achieved if you keep changing it is not surprising that clinicians aredisillusioned with managers.

Manager

Good leaders are willing to make bold decisionsthat challenge the status quo because theybelieve it will improve patient care. Thisleadership is more likely to emerge in anenvironment that allows expertise to matureand the trust between leaders and the localcommunity to develop. Leaders are important inhelping to engage the local community in the

delivery of health services and to overcome theobstacles to change. They can help set thestrategic direction and offer a single point ofreference and responsibility.

Few people doubt the expertise that clinicianscan bring when considering how to changehealth services. Their leadership can draw onthe trust they have built with the localcommunity they serve and underline thecredibility of the plans. This doesnt mean it is

easy for clinicians to become leaders. In fact, itcan often be difficult for them to direct changes

to services they have worked for many years todevelop. Reconfiguration can therefore createtensions between clinicians, although whenconstructive this tension can help test thebasis for change.

Understanding why some clinicians choose tolead is important in encouraging others to leadin the future. The clinical leaders that we spoketo said the main motivation was the desire to

improve services so that they could cope withfuture challenges. This underlines theimportance of having a vision for change that ispositive and based on clinical judgements ofhow the quality of care can improve. This can bedeveloped through tools such as clinicalsummits and clinician-to-clinician workshops.

The introduction of clinical commissioning nowprovides the opportunity for more change to beled by clinicians and to establish a stronger

clinical basis for designing health services. Weheard optimism for the potential of CCGs todrive change and to use their role on localhealth and wellbeing boards to developrelationships across the system. However, to dothis they will need the support and guidancethat allows them to improve services whilemanaging their day-to-day duties.

Leadership should not, however, begin and endonly with clinicians. Managers can have a good

systemic view of health services and are oftenwell placed to understand the wider impact of

Leaders are important inhelping to engage the localcommunity in the delivery ofhealth services and to overcomethe obstacles to change


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changing health services. They will be neededto engage with staff and to develop channelsof communication with them as plans aredeveloped and implemented. There has beengood investment in the development ofleaders in the NHS and we heard that thisseemed to be making some progress.38

However, we were told of concerns about the

relatively high turnover of NHS managers,which makes it difficult for experience todevelop. The managers we spoke to highlightedthat leading reconfiguration could often be athankless task. They told us it was particularlydifficult to give full attention to the complexaspects of change while also managingday-to-day services. It is crucial therefore tohave clear governance within the managementteam, so pressures can be shared and dailychallenges are not overlooked. Relationships

between managers of different organisationscan also provide the impetus for futurecollaborative working around new models ofcare across the system.

What is often ignored by statutory servicesis the potential for patients to be leaders.Patients and their carers have intimate

knowledge of health services and will knowbetter than most the impact that changes willhave. We heard that many patients found ithard to become leaders because they didn'tfeel confident that their voice would be heardequally with those of clinicians and managers.Encouraging patients into these roles willnecessitate that their voice is actually heard;

that they have the support to understand thesystem and its business language; and thatplanning and decision-making processes areadapted for their full participation. The pressureon their time and resources has to beappreciated as many patients and carers havedemanding roles managing their conditionsand/or caring for others.39

Co-production should allow a relationshipbetween leaders to develop and for all local

leaders, whether they be patients, clinicians ormanagers, to feel like equal partners indecision-making about local services. Eachleader will clearly bring their own expertise tothat process, but so long as their role is welldefined they can support the benefits of changeto be communicated and facilitate strongengagement with the local community.

38. A good example is the NHS Leadership Academy's Elizabeth Garrett Anderson programme that offers those from both aclinical and non-clinical background to develop skills to drive and sustain real change building a culture of patient-focusedcare at a wider departmental or functional level. More information can be found at: www.leadershipacademy.nhs.uk

39. The quiet revolutionaries: patient leaders, Health Service Journal (19/02/13).


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Getting communication right

Money is obviously a factor, but there is asense of dishonesty about how change isspun and the motives are oftenmisconstrued.

Patient group

Politicians can provide the political coverthat is needed for reconfiguration but thewillingness is simply not there. Good politicsshould be about honesty.

Phillip Lee MP

You need to understand the different waysthat people get information abouthealthcare and adapt your message to eachof these.

Manager

The way that change is communicatedinfluences how it is heard and understood bythe local community. From what we were told,NHS organisations are beginning to recognisethe importance of communication and moreresources are being committed to presenting apositive public value case to the localcommunity. The concern that we heard was

that this message could be drowned out by anarrative that focuses on what might be lost bychange, rather than the benefits.

All clinical and financial risks and benefits needto be clear and in the public domain, so thatpeople are better placed to understand whychange is needed. It was suggested to us thatsome people may take advantage of this honestyto use in their arguments against change, butoften this information becomes known

regardless. It seems better therefore to be openfrom the start and work to develop trust with the

local community through honest conversations.These discussions shouldn't prevent a positivevision from being communicated, whichhighlights how new models of care can deliverbetter quality for patients and that, while someservices will be changed, greater value will beachieved across the system.

Communicating this message will rely on theability to encourage the local community to beengaged in the conversation about why healthservices should change. This will involve anextensive communications strategy that tries toallow a mature public discussion to take place.Many people told us that this was possible andthat the receptiveness of the public can often beunderestimated. The public might notnecessarily be aware that health services needto change, but they are willing to listen and

discuss why.

Good communication needs to focus on how topresent information in a way that people caneasily access and understand, tailoring themessage to different groups. We heard ofextensive engagement programmes that took alot of time to understand how communitiesaccessed information and went to great lengthsto ensure they were given the right information inthe right way. This could include using websites,

social media, printed materials, radio, churchesand local associations, among numerous tools.

All clinical and financial risksand benefits need to be clearand in the public domain, sothat people are better placed tounderstand why change isneeded


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One important tool is local, and sometimesnational, media. We were told that it can behard to get positive messages communicatedthrough the media, but that it was possible toshow them, if the message was clear, why thepublic would be keen to read about it. Goodrelationships with journalists will probablyalready be in place for most local leaders, but

these will need to be strengthened whenengaging in reconfiguration. Regular meetingsand briefings can help to ensure that they areconstantly informed and to prevent anymisunderstandings. Social media can add tothis by enabling conversations betweenstakeholders that are continuous andresponsive, and an increasing number ofhealthcare leaders are opening up this dialogue,for example through Twitter and LinkedIN.

Politicians, both at a local and national level,have an obligation to represent the views oftheir constituents and this often means theywill want to engage to address concerns voicedby constituents. A number of the people that wespoke to suggested that politicians were oftendifficult to engage and many would be upfrontabout the fact that they would suffer politicallyfrom supporting change in health services, eventhough they might understand the reason for it.The issue of political support in reconfiguration

seemed to be a thorny subject with the peoplewe spoke to, and many felt it was doubtful that

they could alter the political reality. It wassuggested that the best way to get politicalsupport would be to concentrate on building uplocal support, or at least responding to andaddressing concerns that have been raised, tohelp take the sting out of the public debate.This, however, would be less probable asimportant elections approached and political

realities were more likely to take precedence.Getting the relevant service user groupsinvolved in designing the changes will make itharder for politicians to oppose.

Local leaders will need to accept that oppositionwill be inevitable and focus on how to considerthe concerns that are raised. Politicians arefamiliar with debates that have differentopinions and it is important that the case forchange is strong enough so that it can

overcome any case against. Where there is astrong case for change, which is supported by asignificant part of the local community, politicalsupport should, however, be more apparent.Certainly, there needs to be a clearer indicationfrom national politicians of support forclinically-driven change in the best interests ofpatients. Politicians of all colours need to putthemselves at the front of the honestconversation with the public about thepressures that the NHS currently faces and how

the money we have can be spent in the future todeliver the best quality of care for patients.


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There is a tendency not to talk about the financesChange should be driven by a desire to improve quality, but finances will be a factor when changingmany health services. Local leaders need to be honest about the financial risks and benefits to allowpeople to understand the desire to achieve greater public value. Some might take advantage of thisopenness, but the local community should appreciate an honest discussion and carefully considerthe information presented.

Local communities are often unaware of change and the information they get is usually negativeCommunication needs to be an extensive process that gives the local community the informationthey need to engage. This means consulting clearly with all groups in the local community andensuring that the message is tailored to different people. Numerous tools can be employed as part ofa robust communication strategy and they should look to understand who has influence in the localcommunity and how people usually obtain information about their health services.

Politicians are unwilling to engage, but will often oppose any changeThe only obvious way to develop a more constructive relationship with politicians is to build localsupport and highlight the depth of the debate to encourage, at the very least, an open mind. Getting

the relevant service user groups involved and designing the changes should make it harder forpoliticians to oppose. A stronger political consensus is needed at a national level to support changewhen there is strong support amongst patients, managers and clinicians.

Primary concerns about communication


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Getting collaboration right

The local community needs to feel that theyinvented reconfiguration.

Patient group

The closure of any department can have a

big effect on staff. It is a big deal somepeople will have worked hard on their serviceand are devoted to them. Staff need to beactively recruited as part of the solution, notflushed away as part of the problem

Clinician

A routine flaw of reconfiguration is thatthey dont engage early enough with thepublic and community leaders, and whenthey do, it is usually a box-ticking exercise.

Most of those with a stake in reconfigurationdon't feel part of the process and are notinvolved effectively.

Paul Burstow MP

Healthcare should engage the intelligence andimagination of the whole system and bringtogether patients, clinician and managers todiscuss how health services need to be delivered.Co-production is essential to redesign services

and can enable people to feel part of their localhealth services. Collaborative relationships acrossthe local community will be valuable for thefuture, if new models of care are to be developedthat deliver a continuum of care for patients.

An open and mature dialogue across the systemallows perspectives to be brought together andindividual concerns to be raised and addressedcollectively. If every voice is heard with sufficientinterest, this dialogue offers an opportunity to

create a closer association between the localcommunity and their health services.Collaboration does of course take place in most

local communities, but we heard that more wasneeded to understand the variety ofmechanisms that convened people. It is oftendifficult to assess whether discussions onhealth services in one forum complement oroverlap those being discussed in others.

Certainly, many people identified the creation of

local health and wellbeing boards as a possibleopportunity to get a better understanding ofwhere strategic dialogue about the needs of thewhole system could take place, although it wasuncertain what influence providers could havewith such boards. What was clear was thatredesigning services could benefit from beinggoverned by an individual framework to identifyhow co-production was being facilitated.

Staff engagement needs to be considered as

part of this conversation and we were told thattheir role and influence in the local communitycan often get forgotten. Staff willunderstandably have concerns about their jobs,and rumours about change have a tendency tospread quickly though organisations. Resourcesshould be committed from an early stage toengage staff specifically, and they will need adirect opportunity to shape proposals.Openness is important and we were told thatopen board meetings allow staff the

opportunity to input into proposals and witnessthem being developed and to highlight thatthey were being given all the information.

Collaboration of any kind will need to include acentral voice for patients. Co-production mustallow a strong role for patients because healthservices cannot be understood unless they areconsidered through their lives. They know theservices and will be able to offer strategic adviceon how care can be delivered around their

needs. They can also offer a non-institutionalperspective that can test proposals and see ifthey really are more convenient and better for


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patients, and not for services themselves.Quality is about patient experience, as well asoutcomes, and if we are looking to changeservices to deliver more quality, the views ofpatients will be needed to understand howthis can be achieved. Recent investigations ofco-production by Nesta have shown not onlya series of benefits to patient care, but also

the potential to save over 4 billion from theNHS budget.40

We were told that reconfigurations couldsometimes fail to achieve meaningful patientengagement, relying on formal consultationsthat were both too late and unhelpful formany people. There is a legal requirement toengage with the public on substantial changesto health services, although what is importantis the role of patients in helping to produce

changes in the first place. In particular, and ashighlighted earlier, requirements for engagingwith patients so they can produce changes

through the failure regime do not seem to beparticularly strong.

If the patient voice is a whisper at the table, itwill be difficult to convince the local communitythat change is in the interests of patients. Weheard that clear and noticeable involvement ofpatients allows the local community to have

more belief that change is being driven by andfor them. Feedback supported the strengths ofestablishing central patient and publicengagement programmes from the start andclose working with local patient groups. The useof you said, we did tools can also highlight thepower of the patient voice throughout theprocess. It will need to be remembered thoughthat, like with many groups, the opinion ofpatients can be divided. Emotional attachmentsto local services sometimes will override rational

considerations of risks and benefits, and an openand honest partnership with patients shouldallow such divisions to be better understood.

40. Nesta (2013) The business case for people powered health.

The Patient and Client Council provides apowerful, independent voice for people inNorthern Ireland. In 2012, it began a review ofpeople's views on health and social care,

especially in light of the Transforming Your Careproposals to change services, put forward by theNorthern Ireland Department of Health, SocialServices and Public Safety. The councils w

Changing Care Improving Quality

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