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

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Technocracy or politics the process of hospital reconfiguration

Technocracy or politics?The process of hospital reconfiguration

Perri 6, Nottingham Trent University

and

Naomi Fulop, King’s College London


Defining reconfiguration

Defining “reconfiguration”

a deliberately induced, non-trivial change in the distribution of medical, surgical, diagnostic and ancillary specialties that are available in each hospital or other secondary or tertiary acute care unit in a locality, region or health care administrative area


What s it for four stories

What’s it for? Four stories

  • The civil servants’ story: to develop innovation, flexibility, improve access

  • The royal colleges’ story: to ensure enough clinicians in every centre to meet their standards of “viability”

  • The clinicians’ story: to find a way to cope with the European Working Time Directive without service collapse

  • The politicians’ story: to avoid any more upsets like Kidderminster!


Examples of dh approved reconfiguration initiatives

Minor injuries units

Specialist routine elective unit

Telemedicine: digital imaging relay, videoconferencing, CfH, care pathway monitoring

Extended roles for nurses and for non-medical staff: nurse-led clinics, pre-op assessment, prescribing

Ambulatory care incl. One-stop elective day surgery, diagnostics, dermatology

Dedicated routine maternity unit, e.g. midwife-led

Hospital at night programmes: some generic medical roles, senior nurse coordinators

“Networks” (all over again?)

Examples of DH approved reconfiguration initiatives


Sdo study 3 case studies

SDO study: 3 case studies

  • After Kidderminster and “Keeping the NHS local”, DH funded pilots, to be exemplars of reconfiguration

  • At DH request, in 2004, SDO commissioned evaluations of the pilots

  • Quantv. analysis financial and clinical data

  • Qualv. interviews stakeholders and analysis of documents

  • Analysis of “sustainability” of reconfigurations


Trust a

Trust A

  • Merger of 2 urban, inner city DGHs 1999 (500,000 pop)

  • Significant financial issues

  • Single site reconfiguration

  • Senior ministerial interest

  • Separation of elective and emergency care, and redesign of emergency care

  • New building, decreased LoS, greater integration of primary and secondary care, simplification of patient pathway

  • Aug 05: new building nearing completion, some preparatory regrouping within old building; intense pressure due to restructuring at the Trust’s other hospital, continuing problems from merger, some clinical resistance


Trust b

Trust B

  • Merger 3 DGHs, 2002 (570,000 pop) – hospitals X, Y and Z

  • New PFI’s at hospital Z (2001) and Y (2002)

  • Largely rural area, pockets of deprivation (esp round hospital Y)

  • Sustainability issues

  • Multi-site reconfiguration

  • Very influential local Labour MPs

  • Y to focus on elective surgery and emergency medicine; transfer emergency surgery and trauma from Y to X; centralise acute Obs&gyn and paeds at X (move from Y)

  • Aug 05: clinical champions; insufficient funding for full implementation; Y underused; transfers to Y stalled; significant clinician resistance; 3 hospitals still working partly independently


Trust c

Trust C

  • 2 hospitals covering remote rural area – one much larger than the other (400,000 pop, lge temp tourist pop)

  • Geography important: smaller hospital in remote location

  • Issues of patient safety for smaller hospital

  • Multi-site reconfiguration

  • No significant national political interest

  • Cessation of 24 hour medical led emergency admissions to small hospital and development of Medical Assessment Unit working in collaboration with larger hospital

  • Aug 05: Little service redesign implemented, negotiations continuing between conflicting stakeholders: some new roles and protocols agreed, limited joint working


Findings 1

Findings - 1

  • Class and geography: middle class dominated, smaller towns likely to produce more conflict

  • Where reconfiguration perceived as ‘downgrading’ of service provision, more active internal (professional) and external stakeholder involvement (Trusts B and C)


Findings 2

Findings - 2

  • ‘Good’ consultation/stakeholder involvement doesn’t necessarily lead to easier implementation (Trust B)

  • More active stakeholder involvement means reconfiguration plans less likely to be implemented?? (Trusts B and C)


Findings 3

Findings - 3

  • Reconfiguration takes much longer and is much harder to implement than DH documents often seem to envisage

  • Reconfiguration is a complex political process, driven by various stakeholders interests, not just or even very much a technocratic process.

  • Stakeholder interests will play out differently in different contexts


Future of reconfiguration

Future of reconfiguration

  • Patient choice and PBR) likely to result in more reconfigurations to deal with financial pressures

  • Pressure for trusts to become FTs may mean more reconfigurations e.g. current FTs encouraged to take over trusts less likely to become FTs

  • Local conflicts likely to increase if market allowed to work and if it destabilises providers

  • How will potential conflicts between the policies of maintaining local service provision and those creating a market be resolved?


Who wants what

Popularly measured  Technically measured

Output

Residents groups

Clinical professional institutes

Some clinicians

Local councillors

DH?

StHAs, some PCTs, Health economists

Input

Who wants what?

Consumer: service goals

Patient: health gain goals

Taxpayer: value for money goals

Voter: accountability goals


Perri 6@ntu ac uk naomi fulop@kcl ac uk

[email protected]@kcl.ac.uk


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