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The Development and Implementation of NHS Treatment Centres as an Organisational Innovation
Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO)
December, 2006
prepared by
Paul Bate, Glenn Robert Royal Free and University College Medical School, University College
London
John Gabbay Wessex Institute for Health R&D, University of Southampton
Steve Gallivan, Mark Jit, Martin Utley
Clinical Operational Research Unit, University College London
Andrée le May, Catherine Pope School of Nursing and Midwifery, University of Southampton
Mary Ann Elston
Royal Holloway College, University of London
Address for correspondence
Paul Bate
CHIME, University College London, London, N19 3UA
E-mail: [email protected]
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Contents
Acknowledgements 6
Executive Summary 7
The Report 12
Section 1 Studying diagnosis and treatment centres as an
organisational innovation 12
1.1 Introduction 12
1.1.1 Characteristics of a treatment centre 13
1.2 Aims of the study 14
1.3 The study design 15
1.3.1 The qualitative study 15
1.3.2 The quantitative (modelling) study 19
1.3.3 The literature review 19
1.3.4 Reporting anonymously 20
1.3.5 Outline of the report 21
Section 2 Roots and origins – where the innovation
came from 22
2.1 The pre-history and archetype of treatment centres 22
2.1.1 The Central Middlesex Hospital Ambulatory Care and Diagnostic Centre 22
2.1.2 The US ambulatory care model 25
2.2 Treatment centres and the NHS Plan 28
2.2.1 Reducing waiting times 30
2.3 The development of the treatment centre programme 2000- 2004 31
2.3.1 The role of the NHS Modernisation Agency 32
2.4 Summary 33
Section 3 Initial conditions for innovation? The local internal and
external milieus 34
3.1 The internal milieus 34
3.2 The external milieus 42
3.3 The importance of milieu 49
3.4 Opportunists, pragmatists, idealists and sceptics 49
Section 4 Taking up the challenge? The local motives for opening a
treatment centre 54
4.1 Improving quality 55
4.1.1 Patient care 55
4.1.2 Reforming professional practices 58
4.1.3 Promoting training and research 60
4.1.4 Optimising local premises 61
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4.1.5 Improving staffing levels 63
4.2 Improving quantity 65
4.2.1 Meeting performance targets 65
4.2.2 Improving provision of services across the locality 66
4.3 Improving kudos 69
4.3.1 Improving the profile of the organisation 69
4.3.2 Realising personal ambition or vision 71
4.4 Summary 72
Section 5 Environment and influence: the wider context surrounding
treatment centres 74
5.1 The policy context since 1997 74
5.1.1 Policy documents and key events 75
5.2 Independent sector treatment centres 76
5.2.1 First wave procurement: 2003 77
5.2.2 Second wave procurement: 2005 78
5.3 Patient Choice 81
5.4 Payment by Results 83
5.5 NHS Elect 83
5.5.1 Origins and early history 84
5.5.2 Re-launch and expansion 85
5.6 Summary 86
Section 6 Achieving the goals? How the treatment centres
evolved 88
6.1 Planning 88
6.1.1 Incorrect planning assumptions 88
6.1.2 Pressurised planning 94
6.2 The shifting ground 95
6.2.1 The rise of the independent sector treatment centres 95
6.2.2 Patient Choice 97
6.2.3 Payment by Results 98
6.3 Relationships 98
6.3.1 External partners 98
6.3.2 Antagonistic relations 99
6.4 Competition and market forces 100
6.4.1 The lack of a level playing field 100
6.4.2 PCTs and SHAs 102
6.2.3 Marketing to potential users 105
6.5 Internal relationships 107
6.5.1 Recruiting key clinicians 107
6.5.2 Retaining managers 109
6.5.3 Other relationships and systems 111
6.5.4 The parent trust 113
6.6 Achieving targets 119
6.7 The study sites at the completion of fieldwork 121
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Section 7 Improving practice? Evidence of innovation and new ways
of working 123
7.1 Changing practice 123
7.2 Changing the patients’ experience of care? 125
7.2.1 Physical surroundings 125
7.2.2 Innvoations in patient pathways 127
7.2.3 Innovations in staffing 135
7.2.4 Different ‘can do’ mentality 138
7.3 Summary: the struggle for a glass half full 140
Section 8 Quantitative studies related to treatment centre operation
143
8.1 Background – the key role of variability in determining capacity requirements 144
8.2 Example: the use of modelling in treatment centre planning 148
8.2.1 Planned theatre activity 148
8.2.2 Length of stay distribution 149
8.2.3 Results 150
8.3 Extension of modelling to better reflect the context of treatment centre of treatment centre operation 152
8.4 Possible extension of modelling to the case of multiple hospital environments 157
8.5 Modelling outpatient requirements 159
8.6 Summary 161
Section 9 Treatment centres and the efficient use
of capacity 162
9.1 One argument for introducing a treatment centre: managing variability 162
9.2 One argument for not introducing a treatment centre 164
9.3 Comparing capacity requirements with and without a treatment centre 166
9.3.1 The importance of taking a ‘whole system’ view 167
9.4 Modelling the intelligent selection of patients for referral to a treatment centre 167
9.4.1 The interplay between economies of scale and patient selection 169
9.5 Other factors that may influence the relative efficiency of different service configurations 170
9.6 Data collection 171
9.7 Results 176
9.8 Discussion 178
9.8.1 Aside: what if the treatment centre admitted longer stay patients? 178
9.8.2 Caveats 179
9.9 Summary 180
Section 10 Conclusions and discussion of the implications for policy,
concepts, practice and research 182
10.1 Conclusions 182
10.2 The ‘innovation journey’ 185
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10.3 Policy implications of the research 187
10.3.1 The concept of innovation within the ‘new’ Government framework 187
10.3.2 Likely implications for service innovation and improvements 192
10.3.3 Research and policymaking in the NHS: modelling and the conflict of policies 201
10.4 Conceptual implications of the research 203
10.4.1 Planning and complexity 204
10.4.2 Sense-making and decision making 207
10.4.3 Conceptualising key success factors in health care innovation processes 211
10.5 Practice implications of the research 216
10.5.1 For policymakers 216
10.5.2 For change leaders and management practitioners 217
10.6 Implications for research 224
References 226
Appendices 236
Appendix 1 Information sheet for participants 236
Appendix 2 Interview sampling grids 239
Appendix 3 Literature review search methods 242
Appendix 4 Interview topic guides 256
Appendix 5 Results of CHIME survey of treatment centres 259
Appendix 6 An example of a patient pathway 268
Appendix 7 Department of Health’s health reform
framework 269
Appendix 8 Applying the Greenhalgh et al model to
NHS treatment centres in general 270
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Acknowledgements
Contributors to the report
Paul Bate jointly had the idea for the study, participated in designing the
qualitative research, carried out fieldwork at one site, participated in the
analysis of the qualitative findings and participated in writing the report,
taking the joint lead in drafting the final section.
John Gabbay participated in designing the qualitative research, carried out
fieldwork at one site, participated in the analysis of the qualitative findings
and took the lead in writing the final report.
Steve Gallivan led the quantitative research team, the development of
mathematical models to assist TC planning discussed in Section 8 and the
writing of Section 8 and contributed to Section10. He also contributed to the
modelling work discussed in Section 9.
Mark Jit conducted the modelling work discussed in Section 9, contributed to
the design of this aspect of the study and also contributed to the modelling
work discussed in Section 8.
Andrée le May participated in designing the qualitative research, carried out
fieldwork at one site, participated in the analysis of the qualitative findings
and participated in writing the report.
Catherine Pope helped develop the qualitative research design, carried out
fieldwork at two sites, participated in the analysis of the qualitative findings,
participated in writing the report.
Glenn Robert jointly had the idea for the study, participated in designing the
qualitative research, led the sampling, carried out fieldwork at three sites,
participated in the analysis of the qualitative findings, and in writing the
report; he took the lead in drafting Section 5 and the joint lead on the final
section.
Martin Utley devised the theoretical evaluation of TCs with respect to the
efficient use of capacity discussed in Section 9 and led the writing of Section
9 and contributed to Section10. He also contributed to the modelling work
discussed in Section 8.
Mary-Ann Elston carried out the literature review that formed the basis of
Section 2.
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Executive summary
About this report
This three-year study examined the ‘journeys’ of eight National Health
Service (NHS) treatment centres (TCs) as organisational innovations. In order
to do this we:
1 conducted a technical evaluation (incorporating mathematical modelling)
both of the concept and actual impact of TCs as an innovative way of
delivering health care within the NHS
2 studied – using qualitative methods – the organisational and social
factors associated with the development of TCs in order to demonstrate
how these impact upon the implementation process and its outcome.
This report is based on data we collected through over 200 interviews with
key stakeholders within the TCs, their host trusts and their local health
economies; observations of meetings, of TC practices and general
interactions; and documentary analysis of business plans, trust governance
documents and marketing materials. Our synthesis of these data, together
with the mathematical modelling exercises, was used to develop a series of
key findings of relevance to policymakers, service planners, practitioners and
those interested more generally in the diffusion of innovation and change
management.
The cultures of our eight sample sites that chose to open TCs were all very
different. We found a range of management styles, aspirations, interactions
and drivers within the TCs. However, the one factor which united them was
the sense that this particular organisational innovation was timely and
necessary; alongside this we found a ‘can do’ mentality and the presence of
some core ‘champions’ who were keen to implement this new organisational
form. The milieu of the nascent TCs – their local health economy including the
host trust, the primary care trusts (PCTs), the strategic health authority
(SHA), neighbouring trusts, and their own internal staff – also showed a wide
range of relationships that appeared to run along a continuum from hostility
and conflict with most of the major stakeholders, through to much more
harmonious and constructive partnerships with the major players, with
examples of most points somewhere in between these extremes.
The local organisations that took up the challenge of establishing a TC did so
for a wide variety of reasons. In addition to the generally favourable policy
environment, local motivations to open a TC were often rooted in local history
and context (for example pressure to find new capacity to treat patients on
their own or other hospitals’ waiting lists, a stalled plan to relocate surgical
services or open a day-surgery unit, the need to find a use for an underused
hospital building, the chance to engineer changes in local professional
influence, and so on), which conspired to drive each local initiative forward.
While to some extent these motivating factors were unique to each of our
sites, some common features emerged.
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Firstly, the people. The decision to apply for TC funding inevitably resulted
from the resolution of a number of often conflicting views (which we have
referred to as contests of meaning). These were clearly influenced by key
players who were themselves subject to pressures from the internal and
external milieus of their organisations. For example there may have been –
and usually were – idealists who saw the TC as a specific opportunity to
transform patient care. But there were nearly always sceptics who saw it as
yet another fad, opportunists who wanted to secure funding to develop a new
service that was – in their view – much needed, and pragmatists who wanted
to do whatever seemed most likely to improve services with minimum fuss.
Even where there was consensus among those with the power to make the
final decision, there were always discrepancies about their underlying
motivations, rationales and intended outcomes, resulting in evolving and
constantly negotiated clusters of decisions that gradually emerged as
something approaching (at least) some of their initial visions of a TC.
Secondly, a unifying thread in the various reasons why these sites developed
TCs is the sense that they wanted to bring about change – to ‘improve
quality’, to ‘improve quantity’ or to ‘improve kudos’. In improving quality sites
determined to transform the elective care environment (for example new
buildings, infrastructure and clinical and administrative practices). This
included fundamental reform of traditional clinical practices and
transformations in skill-mix. In improving quantity the case studies were
hoping to increase capacity, throughput and activity, and in this they were
tightly coupled to a performance agenda set down by the Department of
Health which was concerned with reducing waiting times and increasing
activity. In improving kudos for the organisation the sites were hoping their
TC would make their organisation more competitive (or at the very least
prevent them falling behind and becoming uncompetitive). Some sites also
used ties with external stakeholders (SHAs, the NHS Modernisation Agency or
the Department of Health) as a way for the TC to improve the profile of the
wider trust (or of key personnel within it).
Thirdly, all our sites experienced a variety of problems related to imprecise
planning, financial setbacks and (usually) overcapacity, and all experienced
some degree of evanescence of some of the original motivators for change,
such as the principle of nurse-led care or other shifts in professional roles. For
a variety of reasons, almost none of the TCs was able to plan and predict with
any consistency or precision even such basic parameters as the numbers and
types of patients they would treat. The way that the TC fared once it had
opened depended partly on the changing state of the local health economy
which was shifting constantly in the maelstrom of central initiatives and the
very varied local responses to them. These included a programme of
independent (private) sector TCs as part of a wider governmental push
towards involvement of the private sector in the delivery of care, presaged in
The NHS Plan (Department of Health, 2000a); the introduction of Payment by
Results (Department of Health, 2002a), a new system for reimbursement;
and the simultaneous introduction of the Patient Choice initiative
(Department of Health, 2003a) and the Choose and Book programme
(Department of Health, 2004a). Many of these had not only indirect but direct
impacts on the ways the new TCs functioned (for example the financial
incentives – or disincentives – for local trusts to send them patients). The
outcome for each site depended on how the managers of the TCs were able to
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respond to this rapidly changing environment, which in turn depended on the
relationships they had with key stakeholders in their local health economies.
In this respect the TC managers and those of their host trust were, by their
responses, enacting the environment with which they subsequently had to
cope (for example, by the kinds of competitive or collaborative relationships
they established with key local stakeholders).
Despite the turmoil, however, there was often perceived to be a positive
impact on patient flows – such as increased throughput and a decrease in
waiting lists – and significant innovations in the processes of care. These
included preoperative assessment done by nurses via a questionnaire, a
nurse-led clinical pathway about which patients were fully informed before
arriving at hospital, well-honed individual care pathways with key milestones
(based albeit sometimes controversially on models from the United States
[US]), case managers in charge of discharge planning, PCTs providing
planned intermediate care, and considerable redesign of the workforce and
the physical environment in order to accomplish these new ways of working.
But often the eventual changes were relatively superficial (‘first order’ rather
than ‘second order’ transformation). By the end of the three-year study, three
of the eight sample sites remained (partially) identified with the NHS-run
programme, one had closed, one had been bought out by a private health
care provider and three were at some stage of becoming linked with the
independent sector. Only one of these appeared to have weathered the storm
by emerging as a stand-alone NHS TC which closely mimicked the original
exemplar of the policy model of what an NHS TC should be.
Finally, while we have shown that it is possible mathematically to model ways
to optimise patient flows and bed capacity, the planning capacity of NHS
management in the frenetic environment in which TCs were being developed
meant that such considerations appeared much less relevant than perhaps
they ought to have been. It was possible through our mathematical modelling
to show, for example, that there were some circumstances under which the
introduction of a TC might be predicted to offer little if any benefit to the local
health economy, and indeed that serious problems of overcapacity might
result (as in the event it did do, in just the kinds of sites that the model
predicted). Yet despite the apparent strength of such logical argument, the
local political and clinical context, motivations and environments would have
made it impossible for such a finding to carry any weight in the complex
evolution of plans, negotiations and implementation that occurred in all eight
case study sites.
Practical implications of the research
For policymakers
1 Top-down, target-led central innovations will inevitably be recrafted at
the local level to suit local needs and build on existing initiatives; they
need therefore to retain appropriate flexibility (headroom) if they are to
be crafted while still successfully fulfilling their core objectives.
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2 Policymakers should try to facilitate local innovation using ‘design
principles’ that acknowledge the likelihood that rational planning of
innovations will be limited in both its feasibility and its applicability in the
‘volatile environment’ of NHS management.
3 There should be more rigorous evaluation of innovative policies while
they are on the drawing board, and where this reveals strong evidence –
for example from modelling techniques – that problems will arise from
the widespread implementation of an innovation, caution should be
exercised.
4 Assessments of the likely impact of new policies on those that are
already working their way through the system should be undertaken
before a new policy is introduced nationally.
5 Even where an organisational innovation has all the attributes of likely
success (for example it is widely acknowledged to have high relative
advantage; it is apparently compatible with the values, norms and
perceived needs of those who are expected to adopt it; and it has the
potential to be adapted to a range of local requirements) there is no
guarantee that it will work. It is also necessary to explore very carefully
the potential interaction between the innovation, its intended adopters
and its context when assessing the likelihood of successful
implementation.
6 Specific training may be required among managers at all levels of the
NHS, as successful implementation of organisation-wide innovations
require a high level of both strategic and front-line change management
skills, which are often in short supply.
7 Where an organisation’s existing knowledge and skills base are
insufficient, then the use of external change agents to support
implementation may be required but is unlikely to succeed unless there
is a common language and values system, and shared meanings between
the policymakers, the facilitators and the front-line innovators.
For change leaders and management practitioners
Service innovation is a social and organisational process, which means that
the management of innovation is predominantly an issue of managing the
social and organisational factors associated with that process. We have
identified 74 such factors from our research on TCs. We have detailed these
at the end of this report in the form of ‘design principles’ for managing
innovation in service delivery and organisation. These 74 principles are
categorised in Section 10 under seven headings:
1 dealing with complexity, non-linearity and unpredictability
2 creating ‘enabling’ structures and systems
3 navigating the politics of innovation and securing stakeholder
engagement
4 building the innovation network
5 creating a learning process
6 changing behaviour and culture
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7 leadership.
Implications for future research
1 Research is needed on the appropriate balance between centrally-
generated innovations and those that are generated locally and
disseminated laterally. The intended shift in the policy environment from
the former to the latter will provide an interesting natural experiment.
2 Work is needed to help develop and evaluate the concept and use of
‘design principles’ in facilitating successful innovation. For example,
within the new NHS policy context it might be possible to work with SHAs
(perhaps using an action research or formative evaluation design) to
explore the place of design principles for organisational innovation at the
local level.
3 The nature and place of ‘positive organisational scholarship’ – a
management paradigm which focuses on positive aspects and identifies
opportunities (Camerson et al, 2003) – should be explored as a means of
fostering a more receptive environment for organisational innovation.
4 We need to understand more about how middle managers such as the
managers of the TCs and front-line NHS staff in general – given their
central role in innovation – make sense of and therefore contribute to
change outcomes in different change contexts. Relatedly, more work is
needed to understand how the inevitable contests of meaning in multi-
level and multidisciplinary organisations can be more successfully
reconciled.
5 What are the sources of evidence that decision-makers draw upon when
making the decision to innovate, and how are these played out in the
negotiations and debates that precede the decision and subsequently
shape its journey? In particular, how do political and power relations and
organisational roles impact on this process?
6 A study is needed to explore the barriers and opportunities for change
based on the findings of theoretical planning exercises and operational
research studies. In particular what might better facilitate the influence
of such evidence on service delivery and organisation within the NHS?
Relatedly, a study is needed that explores the ways in which modellers
and operational researchers might dispel the ‘Cassandra complex’ that
currently affects much of their work.
7 A highly relevant methodological question is how researchers can best
handle the problem of studying an organisational entity that is subject to
a range of – sometimes incompatible and/ or shifting -meanings held by
key players.
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The Report
Section 1 Studying diagnosis and treatment centres as an organisational innovation
1.1 Introduction
Diagnosis and treatment centres were launched as a new NHS initiative with
the publication of the Government White Paper The NHS Plan (Department of
Health, 2000a). As a model of service delivery, diagnosis and treatment
centres sought to streamline patient care, thereby reducing not only the
likelihood of inappropriate delays either in access to care or between care
events but also the long waiting times for routine, short-stay elective surgery
which were plaguing the NHS at that time. The explicit core principles behind
diagnosis and treatment centres were the separation of elective from
emergency and unplanned treatment, and, in line with the ‘modernisation’
agenda, the re-organisation of treatment delivery (and, to a varying extent,
diagnostic services) into more patient-focused processes. Widely proclaimed
as being in the vanguard of ‘modernisation’, diagnosis and treatment centres
were intended to go beyond redesigning treatment spaces and patient flows
to embrace a whole new philosophy of care, one intended to fundamentally
rethink the way health services are provided and maintain the patient-centred
nature of modernisation. This ‘new way of working’ necessitated deep-seated
changes both in how people worked and the culture in which they worked.
The Government’s original aim was that by 2004 at least eight such diagnosis
and treatment centres would be fully operational, treating approximately
200,000 patients a year. It was clear very early in the programme that the
scale of the innovation would be much larger than that, affecting thousands
of staff and hundreds of thousands of patients. A first wave of four diagnosis
and treatment centres was announced in 2001 and a second wave of a further
four centres in February 2002. In the same year came the announcement
(Department of Health, 2002b) that 36 additional diagnosis and treatment
centres would be operational by 2004, 10 of which were to be ‘trailblazing’
new-build centres. The services offered in diagnosis and treatment centres
varied but included ear nose and throat, general surgery, gynaecology,
ophthalmology, cardiology, urology, pain clinics, chemotherapy, sickle-cell
clinics and maxillofacial surgery.
Since those early announcements, the number of service delivery
organisations that come under the banner of this initiative – subsequently
relabelled as ‘treatment centres’ (TCs) – has risen to 46 in the NHS and 17 in
the private sector. The Government expected there to be 80 by the end of
2005 (Department of Health, 2005a). Just as the number of TCs expanded so
too has the list of services offered in these centres, almost all specialties that
can offer routine, short-stay care are now available.
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Whatever the specialty, the defining characteristics of TCs were to deliver
high volumes of high quality care using modern, efficient methods, with an
emphasis on patient choice and convenience. The key was separating elective
from emergency care so that TCs could concentrate on delivering booked
services according to planned protocols. To achieve these aims, there was a
guiding expectation that novel patient pathways would be planned that did
not necessarily treat conventional departmental or professional boundaries as
sacrosanct. The new model of care was expected to be innovative in being
exceptionally patient-centred and, where possible, offering a ‘one-stop shop’
where the provision of diagnostic and treatment services improved both the
efficiency of the service and the experience of the patient.
1.1.1 Characteristics of a treatment centre
These defining characteristics of TCs were frequently reiterated in Department
of Health and NHS material. Such sources also frequently repeated the point
that there was no single model for a TC, whether run by the NHS or the
independent sector. Rather than a single ‘right model’ for all circumstances,
TCs could be anywhere on a continuum from relatively simple primary-care
based developments through to full blown elective ‘factories’, with traditional
day case units in between. For example:
Treatment centres will vary in the types of services they offer depending on the
local demand for health services.
(Department of Health, 2004b)
For the NHS, DTCs [diagnosis and treatment centres] offer an opportunity to adopt best
practice and increase short term capacity through new ways of working. There is not
one prescribed model for a DTC; for example it could be on NHS property or in a
shopping centre. There are no set ideas on structure as long as the DTC is fit for
purpose. Trusts may even want to consider leasing a facility and learning from how this
works before building a tailor-made DTC..
(Ken Anderson, Department of Health, Architects for Health Conference, 2003)
The Modernisation Agency, which had been set up to oversee and guide the
modernising of the NHS had the task of co-ordinating a collaborative
programme to support these developments in TCs. By the time our study
began in 2003, the Modernisation Agency gave the following as a description
of the core characteristics a TC (NHS Modernisation Agency, 2003a):
The goal of a treatment centre is to deliver high quality, cost effective scheduled
diagnostic and/or treatment services that optimise service efficiency and
clinical outcomes and maximise patient satisfaction. The defining
characteristics of a treatment centre are that:
1 It embodies throughout its life the very best and most forward-thinking
practice in the design and delivery of the services it provides.
2 It delivers a high volume of activity in a pre-defined range of routine
treatments and/or diagnostics.
3 It delivers scheduled care that is not affected by demand for, or provision of,
unscheduled care either on the same site or elsewhere.
4 Its services are streamlined and modern, using defined patient pathways.
5 Its services are planned and booked, with an emphasis on patient choice and
convenience together with organisational ability to deliver.
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6 It has a clear and trusted identity that is valued by its patients and by its
other stakeholders.
7 It provides a high quality, positive patient experience.
8 It creates a positive environment that enhances the working lives of the
people who work in it.
9 It adds significantly to the capacity of the NHS to treat its patients
successfully.
We selected TCs as the focus for our study because they exemplified the
increasingly complex and dynamic nature of service delivery innovations,
involving multiple professional and occupational groups as well as major
technological and organisational change.
Being newly arrived on the scene, they also offered a unique opportunity for
us to watch the unfolding of an innovation over time. On this point,
Greenhalgh et al argue that ‘the main gap in the research literature on
complex service innovations in health care organisations is an understanding
of how they arise, especially since this process is largely decentralised,
informal and hidden from official scrutiny. An additional key question is how
such innovations are reinvented as they diffuse within and between
organisations’ (2005, p.17). Studies of major innovations in health care
organisations have seldom been able to evaluate the growth and
development of such innovations over time. Our study sought to address this
research gap by providing a longitudinal analysis of the development of TCs,
from their initial conception through the early implementation, and following
their evolution. The SDO Programme commissioning brief for this study noted
a particular interest in evaluations of innovations which related to NHS
priorities and the implementation of the NHS Plan. This study of TCs provides
a much needed understanding of how one such central component of these
NHS priorities and the NHS Plan is being implemented.
1.2 Aims of the study
Within this context, the overall aim of our study was to describe and evaluate
the way in which the innovation of the TC was implemented in a selected
sample of NHS trusts. Our study focuses on TCs run by the NHS. Private
sector TCs are mentioned in the context of how they influenced the
development of NHS-run TCs; however they were deliberately not included in
our study sample.
The study had two separate strands:
1 a technical evaluation (incorporating mathematical modelling) both of
the concept and actual impact of TCs as an innovative way of delivering
health care within the NHS
2 a qualitative study of the organisational and social factors associated
with the development of TCs in order to explore how these impact upon
the implementation process and its outcome.
We had originally also proposed both to evaluate TCs and to explore how
formative feedback and the sharing of different types and sources of
knowledge (from the two strands of our study) influenced the development of
TCs. In the event, as we shall describe, TCs developed very much as local
solutions to organisational problems in a rapidly changing and sometimes
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chaotic environment. Those planning and running TCs showed little sense of
being a community of organisations implementing a similar innovation. To
have attempted, therefore, to focus on the objectives of evaluation and
feedback of the TC programme would have been neither helpful to those
implementing TCs nor realisable within the scope of this study. Moreover,
such a focus would have drawn attention away from what became the most
interesting aspects of the study, namely the ways in which the innovation
evolved variably in response to the interplay between powerful national and
local forces.
1.3 The study design
1.3.1 The qualitative study
We used a multi-method case study design (Eisenhardt, 1989; Yin, 1994 and
2003). We selected eight case study sites, using the preliminary information
that we had gathered in preparation for the proposal. The selection of sites
was also informed by meetings with the director and members of the national
Modernisation Agency team responsible for the TC programme. The sampling
was intended to ensure that the case study sites provided a broad
representation of the range of TCs either existing or in development as at
March 2003 when the research began. In addition, two of the authors (Bate
and Robert) were involved in an interview-based survey of all the early TCs.
Further details of this work can be found in Appendix 5.
The selection characteristics that we considered were:
• geographical (for example urban/rural)
• type of host trust
• organisational (for example integral or separate from host trust; star
rating of host trust; likelihood of gaining foundation hospital status)
• intended casemix (for example single or multiple specialty, routine or
more complex cases)
• the stage of development (from those that were already open, through to
those in the early planning stage)
• scale (as measured in terms of the number of planned full consultant
episodes or ‘FCEs’)
• new/purpose built or not
• degree of private sector involvement
• commissioning model (for example reliant on multiple or single
commissioners).
Ethical approval for the study was sought from a Multi-Centre Research Ethics
Committee (MREC) in January 2003, and full approval was granted on 14
April 2003. Management approval for the study from the relevant NHS trust
chief executive or TC director in each of the sites was then obtained.
Following changes to NHS ethical procedures the study was designated as a
‘no local researcher’ study in May 2005 by the chair of the MREC which had
originally approved the study and – as such – local ‘site specific approval’ was
not required.
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All but one of our original choices agreed to be case study sites (see Table 1).
The sites were given an information sheet about the study (Appendix 1), and,
when they had accepted, a local ‘site representative’ was appointed from
among the senior staff associated with the TC. With the help of this person,
key initial informants in each site were selected for interview, based on their
roles and involvement with the TC (see Appendix 2 for the sampling grid).
The sites selected ranged from relatively small initiatives (the single ward
that formed stage I of Site B) to much larger enterprises including centres
that operated essentially as mini-hospitals (Sites A and C) and treated twice
as many patients as our smallest site (Site D). Some were complete new
builds (stage II of Site B), some were new extensions to existing facilities
(Sites C, D, H, and G) and some refurbishments of facilities within the ‘host’
organisation (Sites E and F). The earliest date of opening was in 2000 with
the latest (stage II of that same site) due to open in 2007/08. The sites
varied in terms of activity or scale as measured by the approximate number
of patients intended to be treated each year when the TC was fully
operational (measured in ‘finished consultant episodes’). Sites A and C were
expected to have the highest activity, double that of the smaller sites like B
and D. All the sites eventually selected were based in acute trusts and
perhaps because of this most were in urban settings although the
geographical locations covered included city centres, and towns near more
rural areas and the coast. One site had major private sector involvement in
the building work but was an NHS facility. The organisational status of the
sites included trusts with ratings of between zero and three stars; one was
granted foundation hospital status during the course of the study and others
were in various stages of planning to do so.
This fieldwork was undertaken over two and a half years and principally
entailed organisationally-focused interviews with key informants who were
either involved in the design and delivery of the TC or among those
commissioning its services, direct observation of the TC’s workings (for
example the site development, TC meetings and educational events), and
documentary analysis (for example reviewing business plans, board minutes,
annual reports). In addition, to contextualise our case study work we followed
policy changes and undertook a comprehensive literature review of published
and grey literature (see Appendix 3 for details of the search strategies and
Section 2 for the review).
Our intention was to use these data to compile organisational case studies in
order to understand the interactive and political processes which shaped the
development and functioning of the TCs including the roles of key
actors/teams in implementing a new system of care. We hoped also to
understand how the local and wider health economies both perceived and
impacted upon each of the TCs.
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Table 1 The sites
Site Open Scale Physical relation to host hospital
A 2002 7000 Separate site, stand-alone
B 2003
2007
4115 (I) Continuation of pilot in ‘host’, first opened in 2000
(II) New build
C 2005 6588 New build extension to a new hospital
D 2004 3150 New build extension to ‘host’
E 2003 4500 Refurbishment of existing building on ‘host’ site
F 2002 3500 Major refurbishment of private patients wing in ‘host’
G 2003 4600 New build extension to ‘host’
H 2004 3400 New build extension to existing hospital
We carried out the interviews in two phases, the first focusing on the internal
organisation of the TC and its host trust, the second on members of the local
health economy such as representatives of relevant PCTs, SHAs and
neighbouring trusts. We used a snowball sampling technique in both phases,
starting in phase one with the initial key players (for example the chief
executive of the host trust and the TC manager/core team) as identified by
our site representatives. The initial interviewees were asked to recommend
other significant informants and so on until, again with the help of the site
representative, we considered the sample to be complete across all the
relevant parts of the system. We also consulted key personnel at the
Modernisation Agency and several of our sites were members of NHS Elect, a
confederation of NHS elective care providers, which led us to interview senior
staff from this organisation as part of the second phase of our fieldwork (see
Section 5).
Interviews were semi-structured and were nearly all audio-recorded and
transcribed. Most of them were face-to-face, sometimes with more than one
interviewee at the same time. Where necessary in a minority of instances, the
interviews were done by telephone. We used a set of interview prompts to
guide our approach throughout to ensure consistency between members of
the research team (see Appendix 4) and the ‘defining characteristics’ of a TC
as identified by the Modernisation Agency (see Section 1,1.1).
We carried out 201 interviews in all, across a range of categories of
interviewees, who may have been interviewed between one and five times
(Table 2).
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Table 2 The interviewees
Category of interviewee Number interviewed in each category
Host trust
Chief executive officer
Senior trust managers
TC project co-ordinators
TC non-clinical managers
TC clinical leads
TC clinical managers
Other clinical specialists
Other support specialists
5
30
9
24
32
17
7
6
External stakeholders
PCT chief executive officer
PCT senior managers
SHA senior managers
Other acute trust managers
Others miscellaneous managers
TC/Modernisation Agency links
5
9
13
3
6
3
At most sites we also undertook opportunistic non-participant observation of:
1 decision-making interactions, for example:
- formal and informal networking within the TCs, such as project
management meetings, clinical pathways design groups, staff away
days and training events run by external consultants
- between TCs and their parent organisation, for example trust board
meetings which focused on TC-related topics such as capacity
planning, case mix and complaints
- between the TCs and service users, such as patient involvement and
open days
- between TC members at the Modernisation Agency’s learning events
2 the processes of care and the physical environment of the TCs, for
example:
- guided tours of facilities or patient pathways
- visits to building sites to view construction
- staff open days.
We carried out an analysis of a number of documents, including business
plans; minutes from internal TC team meetings and trust board meetings;
protocols and guidelines; press cuttings; key sources of information such as
guidance for clinicians, and information sheets and booklets provided to
patients and their carers. These analyses complemented the data gathered
from the observation and interviews described above.
Because of the emerging emphasis of the study towards organisational and
policy questions, and also because the NHS rules on ethical approval changed
midway through the study, we did not interview patients. This was discussed
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and agreed with the funders of the research at a progress report meeting in
2005.
Qualitative analysis
The qualitative research team iteratively shared and thematically analysed
the data, building theory from the case studies along the lines described by
Eisenhardt (1989):
• analysing within-case data (which involved for each site several detailed
case study write-ups and presentations to the team)
• searching for cross-case patterns (for example selecting categories and
then looking for between-case similarities and differences)
• shaping propositions (an iterative process in which we worked as a team
to sharpen our constructs and definitions, building and re-examining the
evidence to assess the constructs in each case; and where possible
verifying and testing our emerging ideas – often during the interviews
themselves – with those involved)
• enfolding literature (comparison of emergent concepts and hypotheses
with the extant literature)
• reaching closure (deciding when ‘theoretical saturation’ is reached).
1.3.2 The quantitative (modelling) study
We employed mathematical modelling techniques based on probability theory
to evaluate a large number of hypothetical scenarios and thereby identify
circumstances where the introduction of a TC could improve the efficient use
of capacity within a local health economy and circumstances where such an
improvement is unlikely (see Sections 8 and 9 for full details of the methods
employed).
It is important to note that there is a symbiotic relationship between the
quantitative and qualitative research, which may not be fully apparent from
the structure of the report. This is because the structure reflects the different
research methodologies employed, which in turn generated insights
concerning different dimensions of the introduction of TCs. This point is
considered further in Section 10.
1.3.3 The literature review
Professor Mary Ann Elston (Emeritus Professor, University of London) carried
out a review of the background literature on TCs as an integral part of our
research. Her brief was:
1 to track the UK policy literature on TCs
2 to analyse the US literature and identify what lessons have apparently
been taken from the US for adoption in the UK
3 to identify what features delineate critical success in implementing
concept of TCs in the NHS
4 to identify gaps and themes in the existing literature/evidence base to
aid development of research questions in fieldwork and primary data
analysis.
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Additional details of the search strategies used can be found in Appendix 3.
Besides specific searches, some analysis was undertaken of more general
background health services research and policy literature. For example, some
publications on wider aspects of NHS health care policy developments, and
health services research related to organisational change and quality
improvement initiatives (among other things) were referred to in order to
contextualise the TC initiative.
The initial electronic data base searches listed in Appendix 3 generated 470
items. Duplicates, and items about interventions other than those that are
generally planned for TCs (for example pharmaceutical interventions), and
clinical or economic evaluations of procedures (for example comparisons
between day and inpatient surgery) were discarded, leaving 287 possible
items. A further 135 items were added manually as a result of further
searching and citation tracing, and ongoing updating of news coverage. None
of the retrieved items directly about TCs per se (rather than background
aspects or related developments) were research articles in peer-reviewed
journals.
Given this, and the sheer volume and mixed provenance of broadly relevant
material, the decision was taken to concentrate on the greyer, policy-
orientated literature in order to produce a narrative about the development of
TCs. Further selection from within these 450 items (approximately) was
based on perceived relevance to the topic. In all, around 300 items were
directly scrutinised for the review. It should be noted that much of the
included material emanates from government departments and agencies, and
needs to be interpreted accordingly. Journalistic sources will accentuate any
controversial or problematic aspects of TC development.
1.3.4 Reporting anonymously
Confidentiality and anonymity are vital in a report such as this, and were a
condition of site participation. We have therefore deliberately kept the details
of most of the sites fairly vague (such matters as numbers, sizes, budgets,
architecture, job titles and so on) and reported sites in such a way as to try
and disguise them. But inevitably – unless we render all the data so indistinct
as to become useless – the sites will be recognisable to those who are ‘in the
know’ already. Our feeling from the discussions that we had is that those who
are able to recognise the sites will probably not learn very much about what
happened there that they are not already well aware of. On those few
occasions where the point may have personal repercussions, and the exact
source of the quote is not important to our argument, we have kept
quotations but have not attributed the source.
Because we use very general job titles to help maintain anonymity, we have
also used the convention that if there are two quotations in succession from
people with similar jobs in the same site, we refer to the second as, for
example, ‘senior manager II’. But this is merely to distinguish them from the
preceding interviewee, not to label them: in a subsequent citation they would
normally be simply ‘senior manager’. Also to help maintain anonymity all the
sample sites are labelled TCs regardless of their actual titles in the NHS.
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1.3.5 Outline of the report
Section 2 is based on the review of the literature and outlines the origins of
the TC model, both in the UK and the US ambulatory care model, that
preceded the launch of the Government’s TC programme. We explore the
background to that programme, including the reasons behind the initiative
and the intentions that the government and the Department of Health had for
it when they launched it in the NHS Plan (Department of Health, 2000a). We
also briefly outline the subsequent rapid development of the programme and
the part played by the Modernisation Agency. Section 3 describes the internal
and external milieus of all eight sites, which formed the receptive context for
the innovation. We show how varied were the local cultures and concerns that
lay behind the decision to open a TC as part of the national programme, and
we describe the ‘ideal types’ of idealists, opportunists, pragmatists and
sceptics who were engaged in the debates about that decision. In Section 4
we thematically analyse the motivating factors that persuaded the senior
teams in all eight sites to establish a TC in their locality, grouped into the
main categories of:
1 the desire to improve quantity (for example patient throughput)
2 quality (for example patient pathways)
3 kudos (organisational and individual profile and status).
The main government and Department of Health policy initiatives that
subsequently impacted on the TCs, such as the increasing stress on
independent sector TCs, Patient Choice and Payment by Results are set out in
Section 5, which also outlines the development of an organisation of a small
confederation of TCs called ‘NHS Elect’. In Sections 6 and 7 we describe and
thematically analyse how the TCs evolved. Section 6 discusses the ways in
which initial plans rarely worked out as intended, and considers the roles
played by the pressurised nature of the initial planning, by the subsequent
impact of shifts in national policy, by the state of relationships with partner
organisations including the host trust, and by the internal developments and
staff changes. Section 7 describes the stated changes that occurred in the
care patients received, and discusses briefly how this was achieved and how it
was perceived. In Section 8 and 9 we turn to the quantitative study and the
use of mathematical modelling, firstly in the context of TC operation and
planning, particularly in relation to questions of capacity requirements, and
then in Section 9 in identifying circumstances where the introduction of a TC
might improve its local health economy– or not. We conclude in Section 10
with a summary of our main findings, followed by a discussion of the
implications of our research for future policy, practice, and research with
regard not just to TCs but organisational innovations and service
development more generally in the NHS.
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Section 2 Roots and origins – where the innovation came from
This section reports the literature review that was undertaken for the study
(see also Section 1.3.5 and Appendix 3) and seeks to provide important
material relating to the origins and historical development of the TC as an
organisational innovation. An understanding of the history and genesis of this
innovation is crucial to understanding the national and local implementation
of the TC policy and the evolution of this particular organisational innovation.
2.1 The pre-history and archetype of TCs in the NHS
The concept of the TC had a history that began in the UK well before the NHS
Plan (Department of Health, 2000a). Indeed there were some prototype TCs
before this date, modelled on ambulatory surgical centres (ASCs) and other
forms of ‘focused factories’ which had existed in US health care since the
1970s. Neither the archetype nor its context was therefore wholly new to the
NHS. There had been an attempt, for example, to set up a ‘hernia factory’ in
the Midlands in the mid 1990s, and one of our sample TC sites had been
under consideration as a stand-alone elective surgery centre as early as
1997. Some five planned ambulatory care centres in England, two of which
subsequently became part of the TC programme, were referred to in a report
in the mid 1990s (NHS Estates, 1996; p.4) and/or in a later report
commissioned to help in the planning of a number of such centres in Scotland
(Mould and Bowers, 2001). But it was the Ambulatory Care and Diagnostic
Centre which opened at the Central Middlesex Hospital in North West London
in 1999 that was much the most cited as a prototype for the TC programme.
2.1.1 The Central Middlesex Hospital Ambulatory Care
and Diagnostic Centre
The Ambulatory Care and Diagnostic Centre was officially opened by Prime
Minister in December 1999, and heralded as a ‘flagship’ in the Labour
Government’s drive for NHS modernisation. In fact the centre had been under
active development since at least 1994, and was announced in press releases
in 1996 (NHS Estates, 1996), with construction contracts signed before May
1997. The centre was variously described as:
Essentially a hospital without beds for elective procedures.
(Foreword to NHS Estates, 2001)
…the revolution in care that you have pioneered here is to be applied all over
the country..
(Prime Minister Tony Blair, 2001; speaking at the Ambulatory Care and Diagnostic
Centre)
The ACAD [Ambulatory Care and Diagnostic Centre] experience could be
compared, for example, to the experience most people have when they visit a
small airport..
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(NHS Estates, 2001)
The Ambulatory Care and Diagnostic Centre is a purpose-built unit on the site
of, but administratively distinct from, its host hospital. In its early days the
centre undertook pre-booked elective day case general surgery, breast
surgery, ear nose and throat procedures, orthopaedics, gynaecology, urology
and ophthalmology. Inpatient stays – usually of up to 23 hours, but bookable
for a stay of up to five days – were possible in ‘step-down’ beds within the
centre, but were only needed for around five per cent of patients. The
particular distinguishing features of the centre relative to conventional day
case units were the ‘strong emphasis on protocol-driven care’ and the
significant role played by the ‘scheduler’ in the organisation (Bowers et al,
2002; p.306). The scheduler’s role was to make appointments according to
protocols for specific procedures, liaising with patients and/or GPs directly to
reduce non-attendance. Schedulers were said to ‘supersede the roles of
medical secretaries and ward and clinic clerks’ working in teams and directly
responsible to the centre’s manager, not to individual consultants (Morgan
and Layton, 1999). These schedules were arrived at after a detailed exercise
of ‘process mapping’ begun in 1994, in which the team at Central Middlesex
Hospital had developed from simple first principles – ignoring traditional
organisational constraints – integrated care pathways that focused solely on
the needs of the patients undergoing 126 different kinds of elective procedure
(Morgan and Layton, personal communication 2002).
The result, Bowers et al (2002) suggest, of a ‘combination of predictable,
routine patients and a reliable supply of resources [was] to enable the
delivery of streamlined health care with few sources of delay’ (ibid; p.308).
The model of ‘ambulatory care’ adopted at the Ambulatory Care and
Diagnostic Centre was not just of a clear separation of elective and
emergency cases, but handling only those elective patients whose treatment
or diagnostic intervention requirements and suitability for day or short-stay
procedures had been previously determined. Outpatient consultation and
diagnostic services were organised by the main hospital, even when requiring
use of radiology facilities physically located within the centre. GPs were
reported as having only very limited direct access to centre (for minor
surgery).
The Ambulatory Care and Diagnostic Centre was constructed as a purpose-
built, two storey, free-standing unit at the edge of the Central Middlesex
Hospital site in North West London. The building itself has won high praise
from those involved with construction and facilities provision in health care.
‘It has been described as one of the most seminal (sic) health care buildings
of the last decade’ according to the website of the architectural firm
responsible for its design (Avanti Architects, 1999). The building’s innovative
design, the close identification of the NHS Estates unit with its development,
and the fact that the building itself was constructed within contract time (85
weeks) and within budget (around £11m for building costs out of a £19m
total budget) (NHS Estates, 2001), probably contributed to the Ambulatory
Care and Diagnostic Centre’s high profile in UK health care, quite independent
of its clinical or service delivery achievements. The building was designed,
according to the project’s consulting structural engineers, in accordance with
the radical vision of service delivery: separation of elective and emergency
care, allowing ‘walk in/walk out’ patient flow, flexible design to accommodate
future innovation in both equipment and procedures, with quality of space
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valued, no need for traditional wards, and an emphasis on high speed
electronic information storage and transfer.
The skill-mix deployed in the centre and some aspects of the terms and
conditions of service for nurses were different from what was usually found in
acute health care in the NHS. This resulted from a systematic attempt, based
on the process mapping and care pathways work, to redesign professional
roles irrespective of traditional professional boundaries. By 2001, there were
48 full-time equivalent registered general nurses but only nine health care
assistants. Nurses rotated weekly through the different activities in the centre
and were graded for payment/job responsibility purposes not according to the
conventional grades, but into three bands, according to the level of multi-skill
competence reached. Of the many doctors who did sessional work in the
centre, the majority were consultant surgeons, anaesthetists and radiologists,
with only a few registrar grades, the centre not being regarded as a suitable
environment for junior doctors to hone their skills in. At the time of this
review, there were no GPs or staff grade doctors and none of the professions
allied to medicine, other than radiographers working in the centre (NHS
Estates, 2001; p.64-65).
None of this was achieved without considerable internal manoeuvring within
Central Middlesex Hospital, often in the face of strong opposition from
sections of the consultant body. But a strong management team, including
some influential clinicians and academics, was able to achieve the major
changes described in the preceding paragraphs. The motivations behind the
changes were complex, and included: the threat of the hospital’s extinction
unless something drastic were done to give it a unique edge; a visionary
desire to alter the shape of medical and surgical care, based on a local history
of strong interest in patient focused care (linked to a US organisation); the
expectation that the new unit would improve patient flows while reducing
costs; and the need to upgrade poor premises and facilities.
Nothing has been retrieved from the literature search that gives firm evidence
as to the clinical benefits or patient satisfaction at the Ambulatory Care and
Diagnostic Centre compared to a conventional unit. Nor has the search
identified published evidence about cost reduction or cost effectiveness.
Indeed, according to Sillince et al, the claims of 40 per cent predicted savings
which ‘did much to motivate Cabinet interest’, may have been exaggerated as
part of managerial strategy to convince opponents of the need for change
(2001; p.1428). One factor that may have affected financial forecasts is that
the original business plans for the Ambulatory Care and Diagnostic Centre
assumed a competitive internal market, with the centre attracting referrals
from many sources. The change of political climate meant that, at least
initially, referrals were mainly local (NHS Estates, 2001; p.62). The nearest to
a published independent evaluation retrieved was that produced by the NHS
Estates department (NHS Estates, 2001), which was generally very positive,
despite a long list of concerns about the ‘teething problems’, and an admitted
lack of evidence about the costs and benefits of the new service. The
evaluation was undertaken before the unit was ‘fully operational’, and too
soon for any extensive objective data to be collected. However, the conclusion
of this evaluation was that the Ambulatory Care and Diagnostic Centre had
achieved much, and ‘must be deemed a success’ (ibid; p.81):
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It is very early days to draw any conclusions, and as yet there is little if any
evidence to support a claim that this model of care is more clinically effective
than the traditional model. This does not mean to suggest that the ACAD
[Ambulatory Care and Diagnostic Centre] is failing to live up to original
expectations. On the contrary, health care planners should await the
incontrovertible evidence that this is the most effective model of care for future
generations. Evidence-based care is a new science and it is only now that
intuitive practice is being proved to be the best practice in many instances. It is
suggested that intuitive implementation of ACAD may well prove in the future to
be best practice.
(NHS Estates, 2001;p.81)
The Ambulatory Care and Diagnostic Centre became an exemplar, and an
iconic innovation that could be used to legitimise service delivery reform
elsewhere. While no-one would claim that there are no benefits from the
redesigned services of the centre as it has become fully operational, objective
evidence of these benefits is not easily traced in the public domain. It would
appear that, to the extent that the TC programme is a direct descendant of
this initiative, health care policymakers and planners did not await
‘incontrovertible evidence’ of the benefits of ambulatory care, before rolling
out the innovation. It is worth noting, of course, that decisions to implement
new policies and practice without formal and timely evaluation – or without
attention being paid to the results of such evaluations – are not untypical in
the NHS (Bate and Robert, 2003; Sanderson, 2002).
2.1.2 The US ambulatory care model
Much of the inspiration for TCs in the UK also came from the US although only
occasional explicit reference was made to the US model. This influence was
often directly through visits and links with US centres, or indirectly by using
the Ambulatory Care and Diagnostic Centre as the basis for their design which
itself was at least partly inspired by the US model. Ambulatory care of a
similar mould that could also have been a partial influence could also be
found in other developed countries, including Australia, Western Europe, and
perhaps the polyclinics of Eastern Europe, but it was the US that was the
most frequently mentioned.
There are profound differences between the hospital system in the US and the
NHS in England, yet ideas and examples of innovation from the US have been
increasingly influential in NHS policy since the 1980s (Ham, 2005). It is
possible to see some of the key themes in the US, such as hospital
diversification and the decentralisation of services (Stoeckle, 1995; p.13)
being followed in the modernisation programme, including the development
of TCs and their immediate precursors in the NHS in England. It is therefore
necessary to dwell briefly on the US model, if only to highlight the extent to
which policymakers borrowed selectively from it when developing the TC
initiative.
There are of course strong common themes across health care in the
developed world. Since the 1970s, there have been broadly similar policy
debates and changes in health care organisation reflecting technological and
epidemiological developments and political, social and economic changes.
These have resulted in pressure, simultaneously, for cost containment,
particularly of hospital expenditure, and for services that are more responsive
to consumers’ demands. Among the results have been:
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• a general trend of reducing the length of hospital inpatient stay
• a shift of service delivery away from inpatient hospital services to
outpatients or ambulatory-based delivery
• providers’ and policymakers’ interest in re-organising the process of
delivery of health care in ways which may break with established
professional and specialty demarcations, and which seek to increase
efficiency and manage risk through developing more formal protocols and
guidelines
• providers’ and policymakers’ interest in financial management tools, such
as prospective payment systems, and in increased competition between
care providers as a means of controlling cost and raising quality.
The pace and form of these changes have varied considerably between
countries. Therefore, the extent to which other countries have developed
organisational forms of delivery which can stand as comparators or even
precursors to the TC depends on many specific contextual features. However,
one point did emerge clearly from our initial scan of the international
literature: ambulatory surgery appears to have developed earlier and more
extensively in the US than elsewhere. This is not the place to enter into the
socio-economic background to this phenomenon in US health care, save to
point to a number of key features as to why and how free-standing
ambulatory surgery centres were set up and flourished in the US. We do this
in order to stress that although as we have suggested above there are
obvious commonalities with the UK, there are also marked differences.
Firstly, the rise of ambulatory care centres in the US has largely been in
competition with the traditional hospital, part of a general assault on the
‘citadel’ of the hospital, which many commentators describe as having been in
crisis since the 1970s. Secondly, initiatives in ambulatory surgery began to
have an impact on the pattern of surgical services in the US by the late
1960s, and increased exponentially following the establishment of perhaps
the most widely cited example, the Phoenix ‘Surgicenter’ in Arizona. This
pioneering centre had opened in 1970, two years after another such centre in
Rhode Island had opened but subsequently failed due to lack of financial
backing and/or recognition by the insurance industry for facility cost
reimbursement (see for example Berliner and Burlage, 1987). It seems that
ideas along similar lines were springing up across the US and continued to do
so over the subsequent years (Figure 1). This pattern of widespread
exponential growth over two decades is very different from the sudden
explosion of such centres following the central TC initiative in the UK in 2002,
when the US expansion had already run its course.
Thirdly, the ownership and motivation for surgicenters differed from UK TCs in
important respects. The Phoenix Surgicenter, for example, like most of those
that followed, was owned by medical practitioners who established it partly as
a means of solving some of their own frustrations about their professional
lives, for example by reducing on-call/night duties and providing suitable
day-surgical facilities. Doctors ran most of the US surgicenters to manage
elective operating schedules to ensure more predictable working hours, to
defend professional autonomy – particularly in the face of managed care
regimes and corporatisation – and to generate income (Pham et al, 2004).
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Figure 1 Growth of ‘surgicenters’ in the US: 1971-1991
Source: Durant, 1993; Durant and Battaglia, 1993
Fourthly, the growth of surgicenters was associated with the growth of day
surgery (which in the UK had increased, albeit more slowly within hospitals);
with direct consumer demand; federal government and third-party cost
containment policies; overt competition between the different forms of health
care provision in response to cost-containment; and with the relative
attractiveness of surgicenters in terms of cost, planning and regulation and
doctors’ interests (for example income and autonomy under managed care).
To corporate investors in for-profit health care, they promised investment
opportunities that were exempt from state and federal attempts to limit
hospital expansion. To patients and insurance companies and other third-
party payers, they offered the prospect of cheaper facilities than inpatient
hospital wards. Such considerations, like many of the features in the way the
centres were consequently financed and organised, were very different from
the TCs in the UK.
In short, the US centres that served as a model for the UK programme were
very different in many aspects of their organisational governance, finance,
and raison d’être, even though they superficially resembled the subsequent
ideal of the TC in the UK. Yet certain of their key characteristics, such as
patient selection according to strict protocols, the separation of elective and
emergency care and an emphasis on reduced costs and patient convenience,
were selectively borrowed. This occurred despite the fact that there was
almost no formal independent evaluation of the clinical or cost effectiveness
of US ambulatory care and certainly none that allowed them to be applied
with confidence in the UK. Indeed our search of the literature revealed poor
evidence in the US about comparative costs between ambulatory surgicenters
and hospitals. During the controversy that raged over stand-alone surgical
facilities, the arguments for and against revolved mainly around three inter-
related questions, as formulated by Casalino et al (2003, p.57):
1 Do surgicenters provide the cost and quality benefits claimed for focused
factories?
0
200
400
600
800
1000
1200
1400
1600
1800
1970 1975 1980 1985 1990 1995
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2 Do surgicenters have a negative (financial) impact on general hospitals
(individual and/or multi-hospital systems)?
3 Do surgicenters increase or decrease access to care?
Each of these questions is, in theory, amenable to empirical testing yet
Casalino et al (2003; p.60) noted the lack of such evidence when they were
writing and our literature search suggests a similar conclusion.
Surgicenters have been successful in the US, in the sense that their numbers
and the volume of services that they provide have grown rapidly over the last
30 years. However, how they work, and how their quality and performance
might compare with alternative ways of doing the same work is less easy to
establish from the published literature. Our review of the US literature has
found no evidence that specialist free-standing facilities had worse clinical
outcomes or would perform worse on other quality measures than
conventional hospital-based facilities. Indeed, all the evidence found indicated
that overall ‘quality’ and ‘outcomes’ were as good if not better in the
specialist facilities, but this evidence was not very extensive, robust or
generally adjusted for risk. There is some evidence that the case-mix treated
in surgicenters may be less complex, or comprise relatively more socially
advantaged patients. This does not, in itself, indicate that inappropriate or
unethical selection was taking place in the US. If fewer healthy patients were
being treated in the facilities with most extensive emergency back-up and
access to a wide spectrum of expertise, this might be entirely appropriate.
However, at least with respect to patients on the Medicare health insurance
scheme, the payment systems did not give extensive recognition to
gradations of complexity within diagnostic related groups (DRGs), nor to the
possible benefits of physicians having discretion in making referral decisions
for patients with a similar diagnosis but different severity.
The literature reviewed reveals that a highly politicised battle has been taking
place between different categories of health care provider in the US. This
battle has been not simply between for-profit and non-profit providers, but is
one in which the future of the acute general hospital is at stake. This is a
completely different scenario from the UK, yet a recurring theme that has
some resonance is the notion that competition from surgicenters (or TCs)
might threaten or damage the viability of hospitals. It is worth noting here
that this concern – which hints at problems about the market for both forms
of care – was selectively ignored by those borrowing features of the
surgicenters to design the TCs. This ‘blind spot’ about the extent of the
market for surgical work has since become a major problem for many TCs.
While there were limitations in the applicability and the levels of evidence
about US surgicenters, by 2000 the notion had gained momentum and
popularity among key UK decision makers. It was an innovation whose time
had clearly come.
2.2 Treatment centres and the NHS Plan
No central government references to diagnosis and treatment centres as such
have been identified in public policy documents before July 2000, but as we
have shown, there was by now considerable interest in the US and UK
precursors. The NHS Plan (Department of Health, 2000a) provided the
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launchpad of the policy to develop this interest. This document, promising
both major capital investment and organisational reform of the NHS, and a
continuing increase in the proportion of surgery undertaken as day cases,
announced:
Special one-stop diagnosis and treatment centres [which] will concentrate on
performing operations, not coping with emergencies.
(Department of Health, 2000a; p.19)
More specifically the following commitment was made:
In partnership with the private sector we will develop a new generation of
diagnostic and treatment centres to increase the number of elective operations
which can be treated on a single day or with a short stay. These Centres will
separate routine hospital surgery from hospital emergency work so they can
concentrate on getting waiting times down. As a result of this NHS Plan there
will be 20 diagnostic [sic] and treatment centres developed by 2004. By then,
eight will be fully operational treating approximately 200,000 patients a year.
(Department of Health, 2000a; p.44)
Thus, the initial target was specific, but it was to be rapidly exceeded
demonstrating again, perhaps, that this was an innovation readily welcomed
by the NHS. By mid-2004, 29 diagnosis and treatment centres had been
opened, if not all fully operational, and some 80 TCs (run either by the NHS
or the independent sector) were forecast to be at some stage of
development/operation by the end of 2005 (Department of Health, 2004b).
The specificity of the NHS Plan, and the four-year timescale for first operation
of new capital projects suggests, as is the way with most White Papers, that
the new policy initiative was in reality already under development before its
official announcement (making at least some targets easy to reach).
Some features of the NHS Plan were particularly relevant to the TC initiative:
1 In addition to emphasising increased resources, the document was
replete with references to the need for organisational transformation of ‘a
1940s system operating in a 21st century world’ (p15). References to
redesigning services ‘around the convenience and concerns of the
patient’ (p15) to revising and reducing the boundaries between primary
and secondary care, reconfiguration of workforce roles, and the proposal
to establish a Modernisation Agency to support redesign of care around
patients (pp59-60) were employing the language of radical change
through ‘process-based organisational transformation’ (McNulty and
Ferlie, 2002). Although many innovations adopting this type of approach
to quality improvement in the NHS were underway before 1997 (as
evidenced by McNulty and Ferlie’s somewhat critical evaluation of a
business process re-engineering initiative in Leicester Royal Infirmary
which began around 1994), the Government appeared to have embraced
such approaches particularly warmly, notwithstanding some evidence
that changes achieved may fall short of those hoped-for (see for example
Ham et al, 2003). It may be worth noting that the NHS Plan contained
325 instances of the word ‘new’, 70 of ‘reform’, 12 of ‘radical’, and five of
‘transformation, which seemed to set a tone of modernisation and
innovation into which the TC programme fitted very clearly.
2 The NHS Plan presaged the increased involvement of the private sector in
both financing capital expenditure within the NHS and in supplying health
care for NHS patients. The development of independent sector TCs fitted
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within a broader and politically controversial policy framework of new
partnerships between the public and private sectors in providing health
care.
3 Workforce redesign was seen as an intrinsic part of NHS service
improvement: hospital care was set to become more of a ‘consultant
delivered service’ (Department of Health, 2000a; p.78), in association
with extended roles for nurses, implying greater use of protocols. The
Ambulatory Care and Diagnostic Centre was commended for the
extended roles of therapists and for nurses’ work across the whole
patient pathway ‘providing ambulatory patients with real continuity of
care from admission to discharge’ (ibid; p.83). No reference was given to
support this commendation, nor has a published research-based
evaluation been found in the literature search.
4 A major policy aim of the NHS Plan was to ‘wage war on waiting’, and
TCs were seen as spearheading the attack on the waiting list problems
that had characterised the NHS for much of its history.
2.2.1 Reducing waiting times
TCs, together with the national implementation of planned booking of
appointments (see Ham et al 2003), and, later, the initiation of the Patient
Choice initiative (which sought, by the end of 2005, to offer patients waiting
more than six months for elective surgery a choice of provider - public or
private - including TCs) were central components of the ‘radical rethinking’
required to deliver the Government’s waiting-list targets for 2005 and 2008.
Within the Department of Health, the TC programme was set within the
Waiting, Booking, Choice programme whose role was ‘to bring about the
reforms needed to ensure NHS patients get fast and convenient access to
services’ (NHS Modernisation Agency, 2003a; p.2). Capacity shortage
identified by PCTs was a criterion for TC approval by the Department of
Health and additional activity (achieved or target) was the most frequent
measure of the benefits of the TC programme nationally and in local reports.
The inability of the NHS itself to expand capacity sufficiently to meet the 2005
and 2008 targets and ‘to clear real bottlenecks’ was the prime justification
given in public for turning to the independent sector to develop additional TCs
(see Section 2.3). The specialties with the longest waits were targeted by the
TC programme, for example ophthalmology, orthopaedics. By 2002, the
Department of Health identified a new role for the independent health care
sector in providing TCs, particularly emphasising the need for more rapid
growth of capacity than the NHS could allegedly achieve in order to ‘make a
real impact in time for delivering the waiting time targets in 2005 and
beyond’, as well as to ‘lead the way in innovation, productivity and speedy
response’ (Department of Health, 2002a).
The TC programme went beyond simply a substantial increase in capacity
and/or waiting time targets alone. The separation of elective from emergency
surgery, the encouragement of day case or very short-stay surgery, the use
of planned booking and pre-assessment clinics, the changes to skill-mix and
conventional divisions of labour that form the archetypal description of a TC
were all orientated to faster and more predictable throughput of cases. These
reforms were themselves informed by ideas about restructuring hospital care
that had been developing since the 1980s. Thus, while in press releases,
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public relations and general policy documents, the TC programme was
overwhelmingly associated with the targets of reducing ‘waiting lists and
times’, the Department of Health appeared simultaneously to envisage TCs as
a driving force in the ‘modernisation’ process. For example, the programme
was identified as contributing specifically to the Patient Choice initiative and
to other NHS targets, such as reduction in outpatient waiting, increased day
surgery rates, reduction in cancellation of treatment, improving emergency
care access and improving ‘the patient experience’ (Thompson, 2003). The
health care policy community also explicitly recognised the potential of the TC
programme to increase competitive pressures on conventional NHS elective
care delivery, particularly through the envisaged role of the independent
sector.
It is worth noting at this point that TCs were just one of a number of health
care organisational changes and innovations implemented over this time
period. Section 5 explores in more detail the inter-relationships and effects of
a range of these on the TC innovation. At the same time that TCs were being
launched in the NHS a parallel programme of independent (private) sector
TCs was commissioned. This was part of a wider governmental push towards
involvement of the private sector in the delivery of care, presaged in the NHS
Plan but further developed over this time period. The NHS was also preparing
for the introduction of Payment by Results, a new system for reimbursement.
At the same time, Patient Choice and Choose and Book were being
introduced, including an electronic booking system. On top of this, the NHS
was introducing new information technology (IT) systems and working
towards the electronic patient record. It is into this dynamic, complex and
often conflicting world that the fledgling TCs emerged.
2.3 The development of the treatment centre programme 2000-2004
Progress was rapid by NHS standards, with more than twice the number of
centres being at least partly operational by 2004 than had been proposed in
2000. There are suggestions in the health care construction literature that the
pressure for rapid progress brought its own problems. For example, at a
conference in 2003, a speaker from a firm involved with some London TCs
was reported as saying that the politically-driven programmes (‘from now
until the next election’) caused difficulties because ‘clients [had] little
operational policy, no brief and no design, yet [need] to open in 30 months…
This leads to a danger of building the wrong thing in haste. And construction
has to start before design is finished, something we always used to try and
avoid’ (Wainwright, 2003).
All eight of the first wave TCs opened their doors on time (NHS Modernisation
Agency, 2003b). These were Moorfields Eye Hospital, University College
London Hospital, King’s College Hospital, the Royal Berkshire and Battle
Hospital, Weston super Mare, the Royal Haslar Hospital, the Ambulatory Care
and Diagnostic Centre and the Nuffield Orthopaedic Centre in Oxford.
However progress was not, apparently, rapid enough for the Government to
be confident of reaching its waiting list targets by the general election in
2005. In the NHS Plan, the involvement of the private sector in TC
development had been flagged as a possibility but its form left unspecific.
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Many of the TCs run by the NHS were likely to involve some element of
private financing, as was becoming more acceptable in NHS service
development. But in 2002, an initiative to involve the independent sector as
direct providers of TC clinical services was launched, with the clear
expectation that, in the words of the head of the implementation team
responsible for this development that these independent sector TCs, ‘would
have ‘shorter set up times than the NHS is used to’ (Architects for Health,
2003). Since 2002, the NHS and independent sector programmes have been
pursued in parallel. There are reports suggesting that the expected scale of
the NHS-run TC programme under one financial programme was scaled back
in 2003 in favour of full independent sector TC commissioning (see for
example Anonymous, 2003). The development of the independent sector TC
programme is discussed in detail in Section 5.
Shortly after the arrival of a new Secretary of State for Health in 2003,
diagnosis and treatment centres (‘DTCs’) became treatment centres (‘TCs’) in
policy documents. No discussion of the grounds for this change has been
found in the literature retrieved. It may have reflected no more than a
preference for a shorter title in ‘branding’ this initiative, but there may also
have been other possible motives (see Section 5).
2.3.1 The role of the NHS Modernisation Agency
In line with the goals of the NHS Plan, the Department of Health established a
national NHS Modernisation Agency to promote service development within
the NHS. In relation to TCs, the agency had a specific (D)TC team which
developed extensive guidance and ran seminars and training events, and also
provided advice and support to local initiatives. ‘As soon as a new diagnosis
and treatment centre is confirmed, a member of the Modernisation Agency
diagnosis and treatment centre team will get in touch to offer as much
support and guidance as is requested’ (NHS Modernisation Agency 2003a,
p.6). The Modernisation Agency team produced an online guide for those
considering setting up TCs, and its website published information about the
national programme and some individual TCs (at www.modern.nhs.uk) as
well as a number of publications specifically on TCs. These included a
newsletter, Cutting Edge, aimed at those working in or developing TCs, an
overview of TCs as a new service model and a report on lessons from the first
wave TC sites, based on interviews with key informants (NHS Modernisation
Agency 2003b and 2003c).
Based on the experience of the first wave centres the Modernisation Agency
claimed that the biggest perceived risk to the success of TCs was not ring-
fencing them from existing operational activity (and hence encroachment
from emergency demands). They also stressed such things as:
1 the importance of planning and the amount of time needed to get an
operational plan together, and to plan beyond ‘the boundaries of the
diagnosis and treatment centre’
2 not underestimating the time and effort involved in modernising and
refurbishing existing buildings, and that redesign of patient pathways
was very time consuming (some used TCs as a starting point for wider
redesign process, others were pressurised to get doors open before
redesign was completed)
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3 workforce planning - although recruitment could be a problem, the
improved working environment could give a TC an edge over other
clinical areas
4 advanced project management skills and experience in modernisation
and redesign would be invaluable
5 risk management should be addressed by building flexibility into
planning systems
6 the likely difficulty of getting the diagnosis and treatment centre up and
running within the given timescales, and the danger of deadlines being
met at the expense of redesign work, with insufficient time to prepare
the business plan
7 engaging within-site and local community stakeholder interest through a
comprehensive communications strategy, with a long list of the
stakeholders potentially to be engaged, but particularly clinicians, senior
trust executives, SHAs, and PCTs
8 making use of the Modernisation Agency’s expertise and networking
capacity.
2.4 Summary
The literature review suggests that TCs were an idea whose political time had
come. Despite the lack of a strong research evidence base, there were
exemplars or archetypes, largely derived from the US model of the
surgicenter, and realised in the Ambulatory Care and Diagnostic Centre,
which were substantially drawn upon to develop the model of TCs in the UK.
It is also clear that there were strong political and organisational drivers for
this organisational innovation, for example a role for TCs in addressing key
policy areas of waiting times and modernisation that were central to the NHS
Plan and NHS priorities. It is also apparent that the NHS Modernisation
Agency played a vital role in operationalising the policy idea and leading the
early development of TCs.
The next section looks at the initial conditions surrounding the eight TCs
chosen as the focus for our study.
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Section 3 Initial conditions for innovation? The local internal and external milieus
The wide range of organisations that emerged under the banner of the TC
programme (see Section 1) should have come as no surprise. Not only was
the level of variation entirely predictable from previous experience of major
national programmes of innovative service design, such as NHS walk-in
centres, day surgical units and so on, but it had also been anticipated in the
original statements coming from central Government, in the guise of the NHS
Modernisation Agency and the wider Department of Health, and to an extent
in the NHS Plan itself (see Section 2). Such statements, however, implied
that the provision of an appropriate site would become clear from a particular
context, so that variation would arise from a rational analysis of such
considerations as the local need for particular services such as orthopaedic or
eye surgery, optimal geographical location or architectural configuration.
What we found, however, was a much more contingent emergence of local
solutions that depended as much on the local organisational politics, finances,
relationships and culture as it did upon any rational or systematic analysis of
health care needs. We borrow from C Wright Mills’ useful distinction between
milieus and wider social structures (1959; p.8) in the analysis that follows.
For Mills the personal troubles of milieu were separate from (but clearly
related to) the public issues of social structure. We use this idea of milieu to
denote the immediate environment and relations around the TC. In this
section we will therefore highlight the variety of organisational contexts or
what we refer to as the ‘internal milieus’ of our case studies and then describe
each of their external milieus. We use the term ‘internal milieu’ to refer to the
aspects of the TC and ‘host’ organisational structure and culture that we
identified as being particularly germane to the emergence and development
trajectory of the TC; ‘external milieu’ refers to the relevant wider context –
the relationships of TCs with their local and regional health economies.
Section 4 then goes on to describe how and why, given these milieus, the
trusts were motivated to open a TC and how their key actors negotiated their
respective resultant new TCs.
3.1 The internal milieus
What then were the key facets of the internal milieus of our case studies at
the time that the TC programme became relevant to them?
Site A, in a large metropolitan city, had already begun the process of
developing a stand-alone site for elective surgery by securing for itself a
separate budget and management structure that was seen as being ‘separate
.. a little directorate on its own’. The culture was one of opportunism and
entrepreneurialism, an approach that was quickly confirmed when the team
purchased a large existing private hospital on a long-term lease and set about
converting it into a TC that would come to be one of the largest in the NHS
programme. This purchase actually pre-dated the launch of the ‘official’ TC
programme. They appointed a hospital manager with a private sector
background to establish and run the new unit and a charismatic clinical
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director to work with him. This group worked very much through their own
local professional networks to recruit clinicians from across the sector who
would be interested in working at the new centre. Bringing a mould-breaking
attitude of autonomy and ambition, their approach was to emphasise their
differences from the ‘normal NHS’. Although the new unit was very much a
part of the NHS, its location in former private sector facilities and the private
sector mentality encouraged by the senior managers was welcomed by staff,
many of whom had worked in private hospitals previously and had been
handpicked to join the enterprise. The staff consequently saw their
environment as small and friendly, ‘like a family’. However this led to
resentment elsewhere, in the trust and beyond.
They can do whatever they want to do; they can spend as much money as they
want to on agencies. So there was some jealousy and some envy, in terms of
their ability to use whichever agency in the country they wanted to get staff
through the day, because we must make a success of this.... The working
environment is better down there, they’re not ruled by the same set of
guidelines, cost control doesn’t seem to be an issue because you just get those
patients through the door, I don’t care what it costs you, make it work. So it’s
those sorts of things. And they were seen as a bit of a special case. And my
God, towards the end they became my special case. But I think that was part of
the problem, that they were set up as an entrepreneurial start-up business unit,
with, just go do it.
(Site A: trust manager)
As this quotation suggests, the ethos was strongly entrepreneurial, and the
management style one of a close-knit team forging ahead by overturning
conventions in order to blaze a trail for a whole new way of delivering
services quite distinct from the rest of the trust. The team therefore did little
to include ‘outsiders’ (other key stakeholders in the local health economy),
which led from very early in the life of the TC to a tension between the
entrepreneurial ‘go get it’ attitude of the senior protagonists, and the
resentful sense of exclusion among others outside the TC who were not part
of the high-flying ‘family’, but on whom the new organisation might
nevertheless need to rely if it were to flourish.
Site B was a contrasting scenario, a teaching hospital trust in a mainly
working class area of a large city. The trust had been underperforming for
many years, but a new chief executive and other recent changes were
beginning to turn it around. A key part of the turnaround had been to deal
with an overstretched emergency service, which had had major knock-on
effects for their elective services. So, for example, not only was their ‘trolley
wait’ in the emergency department unacceptably long, but the need to find
beds for those patients made them have to cancel operations at an intolerable
rate. Part of this picture was an exceptionally long average stay for
inpatients. The hospital was desperate to solve the problem of bed usage,
which had been undermining its overall performance.
The new chief executive was determined that by challenging accepted
practices and organisational myths that had long been part of the old regime
he would solve such chronic problems and take the trust to a position where
it could achieve its goal of becoming a foundation hospital. He had a
reputation for being performance-driven and hardnosed, and quickly brought
in new senior staff and ‘tried to get them to work corporately and cohesively
and almost kind of sweated the brains a little bit and got them to come up
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with new ideas’ (Site B: senior manager). In the process he had gone from an
inherited top team with around thirty direct reports to only three, and this
had inevitably led to a sense of a widening gap between the executive team
and the rest of the organisation, and a feeling that managers were being
pushed to solve their own problems with little support other than the chief
executive’s backing (in spite of his avowed intention to be facilitative). He
constantly promulgated a set of core organisational values (stressing
openness, honesty, treating staff and patients with dignity and respect;
striving for excellence, listening and encouraging feedback and so on) which
he admitted might sound facile, but which he believed did help to shape
decisions. Some senior managers, however, still worried about a lack of clear
strategic direction; as one of them pithily remarked: ‘The ship at least has a
rudder again, but not yet a course to steer’.
Given their recently delegated powers and reinvigorated positional power, the
new team of clinical directors were beginning to challenge colleagues who
would have preferred things to stay as they were. They encouraged groups of
imaginative and innovative medical and nursing staff who were keen to
improve the service for patients and staff alike, and were already in some
cases seizing the opportunity of the hospital’s change in circumstances to
alter, very capably, the way treatment was delivered. There was a clear sense
developing of a core of like-minded people keen to change things. Using their
technical knowledge, a lot of enthusiasm and effective interpersonal skills,
this group of innovators was gradually spreading acceptance of these new
ways of practising. Without necessarily articulating or making explicit their
new ethos, this core team of people shared a range of ideas and values,
which included a ‘can-do’ mentality, a genuine desire to re-think the way
things are done; a determination to alter the patients' experience by being
more patient-centred; a desire to change professional boundaries and develop
roles that suited the patient's needs; capitalising on the enforced need to
make the hospital more efficient by using it as an opportunity to get people to
fundamentally rethink their practices, a recognition, and exploitation, of the
things that worry and attract doctors; a careful approach to push
professionals, with the grain not against it, as far as they could to change
practices; using prior personal professional connections to reassure people
that they could trust the changes; an openness to new ideas from other
centres; but little concern about evidence of effectiveness. All of these
approaches predated the advent of the TC and the Government’s
modernisation agenda, and Site B, like Site A, had anticipated the change
that came with that agenda. But while Site A was doing so as a separate
entity that stood outside and was trying to leave the host trust behind, the
movers and shakers in Site B were attempting to change the ethos of the
entire trust from within.
Site C had recently undergone large-scale organisational change associated
with moving to a new building. During the run up to the decision to open a
TC, there was an atmosphere of things perhaps not living up to promises. The
chief executive who had overseen the move to the new hospital had just left
the organisation and had taken a few of the key top management team with
him. Others also left shortly afterwards, leaving a some bitterness in the
organisation that careerists had used the move to the new site as a step on
personal career ladders and had not stayed to see the process through. Thus,
at the time that the TC programme was being considered (we were told),
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there was no clear management strategy other than fire fighting, and
managers felt as if they were lurching from one crisis to the next, only able to
hit one target at the expense of another. For example the hospital might
mount a drive to limit the four-hour trolley waits in casualty but in the
process were taking their eye off the equally vital question of keeping elective
beds free for day surgery. Managers, not doctors, were managing the beds,
but were seen as not having a long term interest in what happened, as so
many of them seemed to be moving on. ‘They [senior managers] have no
vested interest in the legacy of what they do’ said one survivor, who had
predicted their exodus.
Reflecting this general situation, the early planning stages of this TC were
undermined by the fact that at senior management level new appointees were
still finding their feet and having to manage other big concerns alongside
planning the TC. There were vacancies in a number of operational roles; there
was a lack of clarity about who should be driving service change, and, we
were told, a tendency to take consensus decisions, which because they were
in fact rarely backed by the whole team often led to paralysis and inertia. The
unfocused managerial milieu within Site C, therefore, contrasted strongly with
the sharp and driven cultures of Sites A and B.
Site D, a small single specialty TC, was set up as a stand-alone unit and
jointly sponsored by a number of trusts in order to solve sector-wide
problems in the services for that specialty. Its management team had close
links with a similar centre in the US, and the management philosophy was
drawn very much from that mentor organisation. There was therefore an
explicit top-down attempt to ‘create culture’ at the beginning, using
organisational development teams and imported managers to promulgate the
ethos of a ‘high performing organisation with high performing people’. The
three key aspirational values as declared in a presentation given by the chief
executive were ‘one – caring for patients, families and staff, a learning
organisation; two – embracing continuous improvement, and pursuing
excellence; three – measures and outcomes’. Nearly 30 hospital consultants
from five hospitals were invited to work at the centre, where they could find
themselves being asked to operate on patients other than their own. However
it was the new nursing roles that initially characterised the TC, which was
intended to be nurse led, and to develop differently skilled nurses capable of
taking many of the roles traditionally performed by doctors and other
professions. The internal milieu at Site D was therefore similar in some
respects to A, in that this centre was highly driven by a strong and ambitious
management team that pursued a separate independent existence and
espoused the values of the private sector, and – as with Site B – used an
explicit set of values to shape the way the organisation was run. It is worth
noting however that Site D was housed in a wing of the parent trust and
relied heavily on the trust for ancillary services whereas Site A was a stand-
alone site and five miles from the parent organisation. This becomes
important when we consider the external milieu at Site D (see Section 3.2).
Site E formed part of a large geographically-dispersed trust around a market
town that had two acute hospitals. When ideas for a TC were first aired the
trust was in debt, with long waiting lists and unacceptable waiting times. It
had rationalised services by closing down the acute and emergency services
in one of the two main hospitals, resulting in local dismay and anger and a
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sudden and unexpected move into the political spotlight. The partly-closed
site later became the chosen location for the new TC. The trust at this stage
was experienced as a disjointed organisation with prevalent feelings of
detachment between the trust’s sites and little sense of cohesion across the
trust. Frequent changes of personnel at senior trust management level –
including more than one change of trust chief executive officer during this
period – added to this sense of a fragmentary organisation with no clear or
consistent direction. Yet despite the disparate lack of focus, there was a sense
that the organisation was not risk averse but parts of it were able – severally
if not jointly – to foster entrepreneurship and innovation in order to
regenerate the trust. Moreover, there appeared to be a positive sense of
loyalty to the individual components of the trust, that is, the acute hospitals
and other outlying services.
Once the idea of a TC had been conceived and a project manager appointed,
this loosely connected organisational milieu of the trust allowed him the
space to construct an organisation within an organisation, ‘a semi-
autonomous business unit’ where his and others’ ideas could be tested and
encouraged to flourish. This individual provided not only clear leadership for
the TC but also a sense that the TC could offer space to focus ideas and
thinking. As the project planning got underway, the TC increased its
independence from the parent trust seeking to achieve status as a separate
entity rather than being fully integrated within the trust. This approach was
greatly helped by the fact that a TC was widely seen as a way to regenerate
the local hospital that had recently been closed; the scheme was therefore
strongly supported across the whole organisation. The project manager’s
vision for the TC was also an important motivating factor. His extensive
previous experience and knowledge of ambulatory care as well as his close
networks with others working in the TC arena (for example prior connections
to Central Middlesex Hospital’s Ambulatory Care and Diagnostic Centre – see
Section 2) gave him both authority and credibility. In both its design and its
philosophy, this TC was built around his acceptance of the Ambulatory Care
and Diagnostic Centre’s view that TCs are about ‘transforming patients’
experiences’ by focusing on ‘a wellness model’, in which the patient ‘isn’t ill
but just needs fixing’. His team supported this view and initially shared his
vision of the TC as having a rejuvenating influence within the local
community and providing a space for innovation, despite some initial teething
problems with timing and design. Under his visionary and innovative
leadership style, they were determined to make this into a showcase TC. In
short, Site E had strong transformational leadership and was functioning as
an integrated but relatively independent and thoroughly different, modern
organisation within an organisation.
Site F was a large trust within a major city. There was a pragmatic, ‘can do’
action-driven culture of opportunism, innovation and risk-taking. It was, for
example, at the forefront of electronic patient records, the new wave of
acquisition of private hospital premises and later of foundation hospitals:
One of the nice things about working for this trust is that there is that capacity
to do things and to drive things forward ahead of everybody else.
(Site F: hospital consultant and manager)
However, the imperative for rapid action often took precedence over analysis,
which was reflected by the lack of detailed planning and organising, in this
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case, around the TC. Typically, strategy and planning was driven – like other
aspects of management in the trust – more by intuition and assumptions than
facts. Senior managers were accused of being attracted to the ‘flavour of the
month’, but having a low boredom threshold, moving rapidly on to the next
project:
It’s as if these are the things [the trust] want to do – okay we want to buy a
private sector hospital for the NHS. We want a DTC [diagnosis and treatment
centre] to play with. So now we move on to the next thing.
(Site F: middle manager)
The trust also betrayed a strong culture of mistrust and adversarialism, as
though everyone else in the local health community were an antagonist who
sent them ‘rubbish’ patients, withheld information, tried to deflect resources
from them, or otherwise slowed them down in their drive to innovate. This
pervasive ‘them and us’ attitude, manifesting itself as derogatory stereotypes
of key personnel in the local health community, or by caricaturing ‘the centre’
of the NHS (that is, the Department of Health and the Modernisation Agency)
as mediocre, risk averse and lacking in innovative ideas, had led to
longstanding tensions. The trust preferred to steer its own path, paying as
little attention as possible to the rest of the health economy, which led to its
being seen by neighbouring organisations as difficult, and as bypassing them
in its relentless quest for innovation and change.
Internally, the trust was strongly segmented into relatively autonomous
departments and professional groups – the word ‘tribalism’ was often used.
For example, although there were some highly effective charismatic medical
managers, many doctors and managers held traditional attitudes of mutual
mistrust and antagonism wherein doctors might typically characterise
managers (who in their view were often transient and inexperienced) as
failing to consult and communicate, while the managers might characterise
the consultant body as a recalcitrant and powerful block to change. As a
senior clinical manager involved in the planning of the TC put it:
There was a lot of unhappiness with the consultant staff, mainly relating to
communication of what was going on. And they felt that all this [the diagnosis
and treatment centre] had been done administratively without any discussion
whatsoever with the consultant staff..
(Site F: hospital consultant and manager)
Individual departments or directorates showed little interest in matters
outside their immediate purview. Other departments could be left to sink or
swim so long as one’s own domain was still flourishing. If another group was
running into political or financial difficulties, Schadenfreude was a more likely
response than co-operative assistance. In short, Site F was a trust
characterised both internally and in its external relations as an ambitious,
risk-taking, competitive, individualist, seat-of the-pants success, riven with
tensions.
Site G was a relatively small trust that in many ways mirrored the sense of
faded grandeur of the adjacent town, a backwater that needed to pull itself
into the mainstream if it was going to thrive. It maintained a strongly
hierarchical organisational structure, where in essence everything went
upwards to the director of finance and the then chief executive. These two
had a long working partnership, predating these particular roles. There was
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clear sense from the staff that personal contact with this top team was a key
to getting things done. The smallness of the trust made this possible; there
was a lot of ‘popping into the office’ to talk to the chief executive. A
traditional doctor-led hierarchy was also a key feature of the culture, coupled
with a small management staff:
[This trust] has got one of the lowest management costs of any trust in the
country and I think it’s been under-managed. If you speak to some of the
medics here they’ve also said that to me. I nearly fell off my chair because
that’s the first time a doctor or a consultant has ever said that to me. It’s been
under-managed and a lot hasn’t happened because there hasn’t been the
management equipped to do things.
(Site G: manager)
The trust was seen from outside as rather ‘traditional’ – even backward.
There were thought to be too few managers trying to cover too much ground
and using very traditional paper-based administrative methods, which meant
that they were usually slower than other trusts in delivering requirements to
the higher levels of the NHS.
The initial thinking about the TC was therefore led by a small team of middle
managers variously seconded to this task. They mainly did this work as
overtime on top of other professional/managerial duties. This small part-time
team had – and created around them – a real sense of team working and a
common purpose. In many ways it initially functioned like an ‘action learning
set’ (Revans, 1998), using the TC project to develop both their own personal
learning and skill development but also that of the organisation. The people
involved were clearly committed to the project and almost jingoistic in their
subsequent recollection of working in the final weeks and days to ensure that
the unit opened on time. One of the foundation myths of the TC, highly
evocative of the organisational culture, was of the chairman of the board
coming in to put up pictures on the walls and getting told off by a cleaner,
who failed to recognise him, for making dust. Thus within the very traditional
history and structure of the trust, there were people there who were keen to
get behind the change and push it forwards. However, they later each
returned to the jobs they had been doing before their involvement in setting
up the TC, and the skills they brought to the project were not developed nor
built upon, reinforcing the view that this was not an organisation ready to
recognise, reward and develop good staff. Site G, in short, was a small town
trust with an old-fashioned NHS administrative culture, under-managed,
subject to the medical hierarchy, and reliant on individual enthusiasm for
change.
Site H comprised two trusts with very different cultures that had recently
merged. As part of a wider reconfiguration of services locally, the smaller
trust, where the TC would eventually be based, was to become a site for
elective activity only. Staff at this smaller trust had traditionally been
perceived by staff at the larger trust as being less empowered to make
decisions and of working in a more top-down organisation. Those staff who
were being asked to move from the larger to smaller trust were generally
reluctant to do so (as the first paragraph of the quotation below illustrates).
Staff at the smaller trust perceived the ongoing reconfiguration as part of the
inevitable takeover of their hospital by their larger neighbour (see the second
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paragraph of the quotation), and these tensions were to have a direct effect
on the development of the TC.
Some of us have worked here for 20 years and we were kind of hoping to retire
working in [Site X], but we’ve accepted that if we want to stay together as a
team, then to [Site Y] we have to go. … Whilst we’re glad that it’s being built on
[Site Y], they’ve got their own worries about the two teams merging because
even though we’re only eight miles apart working in similar hospitals, we do
have very different approaches, and merging the two teams is going to be
difficult ... I think probably the nursing staff in [Site X] are used to decision
making and taking on board more responsibility. I think the [Site Y] girls have
relied on their managers to tell them what to do and not to question why they’re
doing it quite so much...
...[T]hey just have a completely different approach to us and I do think it stems
from management and also, when the two hospitals merged, most of the senior
managers on [Site Y] either resigned or retired. So, most of the senior managers
that are around now were originally [Site X] managers and I think [Site Y] have
always felt that it was a [Site X] takeover. So that naturally breeds its own kind
of hostility. But I have managed the team over there for about four years and I
think they have made inroads, but it has been hard and I myself feel like it’s a
[Site X] takeover really.
(Site H: nurse manager)
The doctors, who were a strong force in both sites, resisted many aspects of
the plan: the idea that only elective surgery might happen in Site Y; the need
to travel between the sites- about 20 minutes apart by car; the prospect of
working in a new unfamiliar environment; the expectation that they would
have to cede control over the booking system for their operating lists and so
on. None was originally keen to champion the idea of a separate site for cold
surgery.
I’m having a lot of problems with the medical staff about it… I think underneath
it all they just don’t want to change. They like working here, they don’t want to
work there. But they’re coming up with all sorts of objections, and this is the
eleventh hour.
(Site H: senior manager)
In fact I’m already aware of heels digging in the sand to say, we [doctors] are
[Site X] based, we can’t possibly go to [Site Y] because we’re very busy people,
and heels are dragging along the lines of, we would really prefer to have our
endoscopy services all in [Site X] and not have them part of this nice new
endoscopy service. We’re just working quietly subtly along the lines of digging
our heels out of the sand at the moment.
(Site H: consultant)
Nursing staff and managers with a nursing background were better disposed
to the merger and the idea of using one of the sites for elective surgery than
were the doctors, but neither they nor the more senior managers felt
empowered or found it easy to push for change:
I wasn’t supposed to hear, but they [nurses] are happy, in between the
grumbles…. we’ve been encouraged as team leaders to have meetings with the
clinicians, but it is quite difficult. We don’t know what we can offer them
financially and we both feel it will just end up as a shouting match. So we’re
trying to get them when they’re on their best behaviour and get a few clinicians
into one room. They’re all going to want to out-shout one another and it wouldn’t
be sensible for either of us to chair a meeting I don’t think. I feel we would go
down rather than up in their estimation.
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(Site H: nurse manager II)
Unlike the other trusts, the chief characteristic at Site H was a post-merger
‘digging in of heels’ by a consultant body who were unwilling to accept the
need to change their practice, and whom the managers generally felt unable
to persuade easily. There was also a sense that while some individuals were
positive about the TC there was a general lack of ownership by staff.
This sketch of the internal milieus initially suggests little similarity between
the cultures of the sample sites, all of whom had decided to open a TC. There
was a range of management styles, aspirations, relationships and pressures
that characterised each of the eight sites. However, one factor that unites all
the sites was, albeit variously expressed, a sense that this particular
organisational change was timely and necessary, and with this a ‘can do’
mentality and the presence of at least some core ‘champions’ who were keen
to implement this innovation. Thus at Sites A and E we saw
entrepreneurialism, Site B was ‘looking to change’ Sites D, F and G were
‘driven’ and held together by a common purpose. The exception at this early
stage was Site C which was characterised by weariness with change. It is
worth noting that this was one of the later sites to open and that this
weariness was explained by the relatively recent move into a new hospital
building. Later in the development of this TC a dedicated TC project manager
was seconded to oversee the project and the internal milieu at this site began
to resemble more closely those of the other seven sites in our study. Before
examining in Section 4 how these situations affected the emergence of the
eventual TCs, we turn to a description of the external milieus of the sites.
3.2 The external milieus
It will already have been apparent, that Site A – the newly acquired private
hospital premises with ambitions to provide a single specialty service across a
wide metropolitan area – had very little support and indeed endured
downright hostility from most of the local trusts. Moreover it was doing very
little to engage the key stakeholders across the local health economy. As a
senior manager in the SHA told us:
Yeah, it came completely out of the blue. Nobody knew anything about it. I still
don’t know whose decision it was or whose idea it was or who was the driver.
Because of that, it raised immediately antibodies all over the place.
(Site A: senior manager)
The antibodies were all the stronger because, in a sector where most of the
NHS was already struggling financially, a six figure sum had been top sliced
from all the local PCTs to fund the new unit. Complex financial arrangements
were set in place that neighbouring trusts were predicting (rightly as it turned
out) would disadvantage the hospitals that were expected to send their
patients to the new unit. Nearby hospitals felt that this new development
meant that not only was the host trust, a teaching hospital, taking their more
complex and interesting patients, but now its unit was going to take their
routine elective patients too. Some saw it, therefore, as a takeover bid
destined to undermine other local hospitals in the whole area. The way in
which the surgeons were handpicked from among the network of the unit’s
senior team was an added irritant:
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So they had no choice. So here we are, here’s [the new TC]: use it! Now, if
you’re sitting in a hospital … and none of your surgeons have been chosen to
be part of that, you’re going to go, ‘I don’t think so’.
(Site A: senior clinical manager, host trust)
For Site A, therefore, the TC was being brought into a fairly hostile world,
which would inevitably make life difficult for it. This was a stark contrast to
Site B, where the local health economy was hardly aware of, and almost
unaffected by, the notion of a TC within that site. Site B, one of two main
university hospitals and somewhat the junior partner, was in a region that
had been relatively poorly funded and lacking in region-wide strategic
thinking. The region was now making amends with several major planning
initiatives most of which were based on strong aspirations to improve, and
shift the emphasis towards, primary and community care. There was,
however, little regional strategic thinking about hospital provision; instead
there was a sense of all the local trusts carving out their own space and their
own futures.
We recognise that what happens in the NHS in [this region] is that every trust
has resolved its own problem
(Site B: senior manager)
In keeping with this philosophy, early discussion about opening a TC was
largely an internal matter concerning the rearrangement of patient care in
order to tackle some of the internal problems of chronic bed shortage. While
necessarily involving the regional authority and local SHA to approve the bid,
the trust was able to plan and open its first phase TC without any
involvement from local PCTs, trusts and GPs, to whom the new unit was
almost invisible. Thus, although the trust managers wanted to move ahead
quickly to implement what was almost entirely an internal initiative – and
moreover one that had direct support from the Department of Health and the
Modernisation Agency since it would not only help achieve the targets but did
involve a strong element of ‘modernisation’ – the SHA and region took several
months to satisfy themselves that the bid was genuinely within the spirit of
the TC programme. Mutual relations at this time could be described as
smooth if slightly impatient. However the second phase plans to open a fully
fledged TC three years later along the lines of the Ambulatory Care and
Diagnostic Centre became ensnarled in a growing tussle between the push
towards rationalising services across the region and the need for the trust to
solve its own performance problems and maintain its role as a leading
teaching hospital in the city. At the time of writing, more than five years after
the first phase was opened, the Phase 2 new build is still at the planning
stage.
Site C, still recovering from its recent move to a new hospital, had an unusual
but important and influential external link, namely the (private sector)
contractor who had built the new hospital, and who would need to be involved
in the new TC. The relationships with the builders and project managers for
this part of the TC project were in essence a re-run of those built up during
the recent transfer to the new hospital – but on a smaller scale. The obverse
of this was that the trust was also the focus of a great deal of (hostile)
attention from the NHS trade unions coupled with some adverse local political
action.
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Relations between the host trust and the TC were good. Indeed within the
host trust, as will have been clear from the description of the internal milieu,
the TC was just one of many management agendas, so that the TC’s internal
structures were closely, often inseparably, linked with those of the trust. For
example, bed planning discussions about the wards in the TC were integral to
discussions about bed configuration across the whole trust. At all the
meetings about the TC the key senior/middle managers also held
trust/hospital posts, which inevitably led to a ‘whole system approach’.
However it also meant that the TC planning process suffered from the lack of
necessary focus and attention until (at the SHA’s suggestion) a project
manager was appointed, allowing the TC project to acquire more consistency
and drive. As this intervention suggests, relations with the SHA seemed good;
it played an important role in helping to shape the project management while
the TC plans were being developed. As for the local commissioners, nearly 60
per cent of activity came from a single local PCT; both geography and history
made Site C the natural provider for this PCT. However, two neighbouring
PCTs had recently become dissatisfied with the performance of the providers
they usually used. They therefore agreed a contract during the planning
phase of the TC to remove their contracts from that hospital and bring them
to Site C, thus promising to supply around half of the expected TC patients.
This agreement formed a key part of the original TC plans.
Site D was intended to provide a service across several trusts, but was
nevertheless a subunit of one of them. The TC managers did not favour this
arrangement and from the start wanted to be ‘completely stand-alone’. The
result was tense compromise: the beds were completely ring-fenced and the
chief executive of the new centre described himself as not working for the
‘host’ trust directly. Officially the TC was designated the status of a Division
by the host trust, distinguishing it from a standard service directorate and (as
stated in the clinical governance documentation, for example) ‘recognising a
degree of quasi-autonomous operational independence’. Nevertheless the TC
was reliant – reluctantly – on the host trust for such services as human
resources and finance. Senior staff at the TC were continually troubled by
what they called ‘the politics of being hosted by another institution’ that did
not understand the principles of the TC and what it was trying to do in the
way of reshaping patient pathways and staffing. They wanted to ‘employ our
own… start as we mean to go on’, ‘starting from scratch’ they often talked
about ‘throwing away the rulebook’, and wrote their own job descriptions
even for human resources and finance staff so that they could be shown the
different culture/way of working the TC had. But rather than being allowed
the freedom to go forward, they felt held back by the trust, who seemed to
frown on their innovative ideas, constantly demanding justification for the
new ways of doing things and delaying progress. The TC very quickly ran into
major problems when trying to recruit clinical staff to new roles in line not
only with the modernisation agenda of nurse-led patient pathways but also
with the Government’s Agenda for Change document (Department of Health,
2004d). Yet the trust ‘went ballistic’ because this contravened their staff
gradings and the TC ‘had to come back into line’.
Some TC personnel felt that the host hospital was not merely questioning
innovative practices but was positively cynical about the venture,
apprehensive about accepting the risk of responsibility for the TC, resentful
that the TC was poaching some of the best staff, envious that it was receiving
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special favours, and secretly hoping it would fail. Clinical governance was one
of the foci for this underlying tension with the host trust, who saw the TC as
inherently risky because it was doing things unconventionally; not least
perhaps because it was intended to be nurse-led which had already raised a
few eyebrows. To some extent these concerns were shared by some of the
external stakeholders such as the PCTs who were expected to provide
patients, and who felt their concerns about risk management and governance
were not being properly addressed. Exacerbating these problems was the fact
that although the TC had been long in the planning and had secured the
support of most – if not all – of the local chief executives, in the months
before it opened all of these senior supporters had gradually left the
organisation. Many of the central features of the TC (being nurse-led, almost
self-autonomous) were less well understood, or approved of, by the newly-
appointed senior managers. The chief executive of the new centre felt he had
to sell the concept to all these key stakeholders all over again.
The several PCTs for which the TC was to provide the specialist service had
other misgivings too. Although they varied considerably in their views about
the short lengths of stay of postoperative patients, some were very concerned
that the early discharge (based they said on a system in the US that had the
benefit, not here present, of a step-down facility), would put too much
pressure on primary and community care. There was a lead purchaser from
among the PCTs present at the meetings, but discussions were impeded by
the lack of continuity of PCT representatives, who changed from meeting to
meeting. Thus, despite the TC’s intention to be ‘meticulous’ in its
communication and involvement with the client PCTs, the resulting links were
not very satisfactory and many deeply held concerns remained unresolved in
the eyes of key external stakeholders.
The local SHA and workforce confederation, however, were supportive of the
direction the TC was taking. Finally, the TC had ambitions to bring in patients
from beyond these PCTs and their four local trusts by becoming a major
supplier of services under the Patient Choice scheme; initial negotiations
suggested that this would be a fertile source of patients. However this was
never to materialise.
At Site E, before any real thoughts of creating a TC, the trust had been
catapulted into the political limelight through the local community’s action to
initially fight the hospital closure and, when that had failed, to get acute and
emergency services reinstated to the area. Despite the turbulent relationship
with the local community the trust had generally good relationships with the
PCTs and the SHA. As the project began to get off the ground the new project
manager fostered these harmonious relations. The local PCTs and the SHA
signed up to the idea of creating a diagnosis and treatment centre on the site
of the closed hospital, seeing its potential for reducing waiting times across
the health economy and also the possibility of offering some acute services
for local people to use.
The TC was seen to fit in very well with the local development plans... as it
provides the opportunity to have more activity up in [Site E] – releasing
resources, freeing up pressure, I suppose, at the main acute hospitals.
(Site E: senior manager, local PCT)
The TC manager made a point of including representatives from the local
health economy (its three local ‘partner’ PCTs and the SHA) in decision-
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making through their membership of the TC’s clinical board. All parties
recognised the benefits of forming close working relationships:
It’s a step into the unknown. If we approach it positively and constructively,
then I think that it could be a significant resource. If we get lost into all kinds of
inter-organisational arguments and bickering, then we could very quickly lose
the benefit that it would have to offer.
(Site E: senior manager, local PCT)
The three local PCTs, who soon represented their views through one lead
chief executive, also established a degree of flexibility within the
commissioning process as activity levels were shared across the three PCTs.
They welcomed the potential for the TC both for patient choice and for
improved services:
It does provide another opportunity for choice. It’s a separate location for choice,
which is very helpful, and I think that my GPs have recognised that that is a
significant additional opportunity for speedy access. I think that’s the plus.
(Site E: senior manager, local PCT)
…we can guarantee you access and we can guarantee that complication rates
and infection rates will be significantly lower than if you went into what you
would perceive to be a traditional hospital.
(Site E: senior manager II, local PCT )
However all was not straightforward: the most local PCT, which shared the
hospital grounds, tried (ultimately unsuccessfully) to ‘take over’ the running
and ownership of the TC. This experience was later to predispose the TC to
broaden its patient base from much further afield as a way to protect it in
future from local competition or predators. The SHA saw the TC as ‘fulfilling
the new consumerist model of care espoused by the government (care when
you want it, in a good environment)’ and were keen to champion its use
beyond the neighbouring PCTs; indeed key SHA staff were constantly
reminding them that the TC would be an option for their patients. When later
this began to happen, the TC, although valuing their contracts in terms of
filling space and providing revenue, did not accord these outlying purchasers
such close ties as the more local PCTs; none were represented on the clinical
board and the TC manager either dealt with each individually or through a
brokering trust (for example one PCT in another county bought services from
the TC through their local acute trust). These more distant PCTs, on whom
the success of Site E might partly depend, had mixed feelings about the
usefulness of the TC – later on some found it to be a useful addition to their
facilities.
The treatment centre provides the opportunity to have more activity … releasing
resources, freeing up pressure, I suppose, at [our] main acute hospitals …
(Site E: PCT chief executive)
But others were less positive, feeling that they were disadvantaged in
negotiations related to price and case-mix and, as a result of this, preferring
to use services closer to home. One director of finance who initially contracted
with the TC for a small amount of services (in the region of ‘a score of
patients a month’) for his acute trust and a PCT 35 miles away chose, later,
not to renew the contract for a second time preferring to use the more local,
more extensive, cheaper provision that had been developed.
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But the main problem we’re having is the relatively restrictive list of procedures
and the prices they charge making them not particularly attractive and certainly
no more attractive than some of the [local] private sector. Also, the private
sector, even if they’re slightly more expensive [may] do a volume deal.
(Site E: senior manager representing neighbouring acute trust and PCT.)
During the planning phase strong ties also began to develop between the TC
and the Modernisation Agency. The project manager drew heavily on what he
saw as the Modernisation Agency’s emerging ethos for a TC – one in which
care was based around:
…making smoother journeys for patients, taking direct referrals for elective
surgery, focusing services around patients… and providing diagnostic services
(Site E: diagnosis and treatment centre project manager)
From the start, the Modernisation Agency regarded Site E as one of its model
TCs and indeed later on in the evolution of this TC this relationship became
even stronger. For example as the TC developed, the project manager and
the matron/clinical manager gave presentations and supported poster
displays at learning events run by the Modernisation Agency. The agency’s
liaison officer for Site E described it as ‘very much along the core
characteristics that we try to promote, and they work very hard to achieve
that, more so than many of the other treatment centres. I think there are two
advantages that they’ve got - one is that they’ve got (a project manager)
there with his experience which has helped, and the other thing is the fact
that they were one of the first mixed speciality treatment centres to open’.
Site F – a major teaching hospital – was not in a happy relationship with most
of its external stakeholders who resented its competitive, even predatory,
approach to service planning and provision. However, patients came to the
hospital from a very wide range of sources, which left the trust less reliant on
any particular local PCT (in contrast with, say, Sites B and C). The many
meetings in which the trust liaised with key local stakeholders necessarily
covered a large agenda, and the TC was rarely mentioned. But the
adversarial/ethnocentric attitude of the trust may also have led the trust
managers to keep their cards close to their chest as they were planning the
TC, and certainly the external agencies felt that the trust had deliberately
excluded them for the decision-making:
The treatment centre... slightly bypassed conventional NHS planning and a lot
of that is down to a very entrepreneurial chief executive they’ve got at [Site F].
But the perspective I had was that [Site F] was extremely opportunistic and
lobbied directly, if not at Number 10 level, then certainly at Department of
Health level and really bypassed health authorities and general planning
measures, and negotiated directly with the politicians and senior civil servants
about the establishment of the [TC]. So I think it was a bit of a surprise to
people that [Site F] had acquired this [TC] and didn’t particularly fit in with the
normal capacity planning processes that you’d expect people to go through
before discovering the new service entity. Presumably the PCTs were just
coming into being then as well and I think you’ll find they were pretty much
bypassed as well in the discussions.
(Site F: manager, SHA)
The PCTs did indeed play very little role in commissioning care at that stage
and negotiations, such as they were, were mainly confined to the SHA and
the Department of Health. Indeed when the local PCT did later get more
involved, the trust simultaneously, and without the PCT’s knowledge,
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negotiated via the Patient Choice initiative to get additional patients at a
different rate of payment, leading to a flurry of accusations and counter-
accusations of spurious billing and ‘double counting’ of patients that were
symptomatic of this lack of trust between the commissioners and the trust.
Site G’s dealings within the local health economy were mainly with five PCTs,
and relations were generally very good. The key local PCTs were satisfied that
they had input into the planning of the TC, and the SHA were supportive, too.
Indeed the latter played an important role in expanding the original idea of a
day surgical unit and suggesting doubling the capacity and applying for
funding from the TC programme. This was despite some concerns – which
had to be taken account of – that the new facility might weaken the position
of a nearby teaching hospital.
Finally, at Site H the main aspects of the external milieu that affected the TC
concerned its host trust. The trust, due to the internal politics of the two sites
(see internal milieu above) had wanted to steer clear of a ‘hot’ (acute) and
‘cold’ (elective) site hospital by opening a TC on both sites, but the external
bodies such as the region and local PCTs disagreed. Indeed the plans for the
TC were affected very early on, before an outline business case was even
begun, by a strategic overview of services being carried out at the regional
level. Once the idea for a single TC had been agreed within the regional
strategy, the region and the two main local PCTs had little further
involvement; they regarded the setting up of any such unit as largely an
internal matter, although the two PCTs did each contribute a five figure sum
to improve staffing in the areas of patient activity that were expected to be
covered by the new unit. This lack of involvement may have been because
the new unit was considered simply to be an integral part of the hospital
trust. Funding, staffing and governance within the TC were part and parcel of
the overall strategy for its host trust – including clinical governance even
when the teams of surgeons working in the TC might be brought in from
overseas to carry out the operations. This also meant, however, that the TC
was subject to internal management reorganisations and financial
retrenchment when the trust ran into financial difficulties. These financial
setbacks in the host trust resulted in a significant scaling down of the planned
operation of the TC, and frustration among those responsible within the TC
for delivering the intended improvements and modernisation of services. It
also resulted in the transfer of some of the more specialist areas of TC work
into direct provision by community clinical services run by the PCT.
This examination of the external milieus of our eight sites did not reveal a
unifying theme. The range of relationships described here appear to run along
a continuum, with Sites A and F characterised by hostility and adversarial
relationships with most of the major stakeholders within their external milieu,
through to E and G which appeared to experience more harmonious and
constructive partnerships with the major players (albeit at E this was
underpinned by political necessity). In between these there is apparent
disinterest (Sites B and H) and a more mixed picture of tense, or at least less
helpful, relationships (for example between the local trust partners at Site D,
and with PCTs at C) alongside other more supportive stakeholders.
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3.3 The importance of milieu
The internal and external organisational milieus around our case study sites
were clearly influential in the initial development of these eight TCs. In
particular we have seen how important the internal milieu was in providing
the necessary leadership and a supportive ethos (even if this was sometimes
confined to a small inner team). The key relationships driving the TCs’
development were rooted in local historical and cultural contexts, but
nonetheless from these milieus emerged players/actors who would take the
TC forward.
Given the policy rhetoric about strategic planning and the pivotal role of PCTs
in shaping health care provision (espoused in the NHS Plan as well as other
statements from central Government [Department of Health, 2000a; 2001;
2002b]) the lack of serious engagement of many of the TCs with their
external milieus was perhaps surprising. As our data show sometimes it was
not simply that the external stakeholders ignored these local initiatives; they
were hostile from the planning stage onwards. While during this initial phase
of development the nature of the relationships with external stakeholders
appears to have had little real effect on the emergent TCs (who appear to
simply ‘get on with it’), as we will see the external milieus took on greater
significance at later stages in the development of these TCs.
Having noted the importance of local context, champions and relationships,
we also explored the roles of some of the key local players whose actions
helped to shape the development of the TCs, for it was such local actors who
moulded the rationales for and against the innovation into the eventual TCs
that emerged.
3.4 Opportunists, pragmatists, idealists and sceptics
The rationale for TCs (set out in Section 2) promulgated by the government,
the Department of Health and the Modernisation Agency, may seem a priori
to be clear: reducing waiting lists and modernising care pathways. However
as we have seen, the local justifications were the result of more complex
‘negotiations’ between different groups or ‘players’ within each site, each of
whom interpreted the innovation differently. At each site there were ‘contests
of meaning’ as different understandings and definitions of what a TC was and
meant for the organisation were played out in the early phases of the
development of the TCs. We are interested in these contests of meaning
because they reveal how TCs were understood, but also the powerful
dynamics which motivated the development of these sites (to which we turn
in Section 4). We anticipated that in looking at the motivations for developing
a TC we would see evidence for a negotiated order (Strauss et al, 1963;
Strauss, 1978) that is, in the presence of formal organisational goals (for
example the TC policy) there would be transactions, disagreements and
bargaining between actors which would shape the resulting organisational
structure(s). In the event we found little evidence for the types of clear cut
inter-professional negotiation described by Strauss et al (1963) but as a way
of making sense of what was happening at each of the sites we were able to
delineate four key groups of players who seemed to have a role in
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determining the fate of the innovation. Of course, our fieldwork, much of
which was interview based and therefore reflected events through the eyes of
the informants – can provide only some indication of the ways in which the
decisions were played out.
We characterise the four ‘ideal type’ groupings, which help to illuminate the
nature of the stories presented to us to explain the development of the case
study TCs, as opportunists, pragmatists, idealists and sceptics. We are
reassured that other literature makes reference to similar groups. For
example Traynor (1999) identifies four comparable groups in his analysis of
managers in nursing. Indeed the NHS Modernisation Agency (2002) has
produced a report about the role of sceptics in change management. The four
groupings can be depicted as follows:
• Opportunists saw TCs as a chance to do something (rebuild, expand,
renew), often something that had already been planned or was
developing.
• Pragmatists focused on local, practical issues, notably delivering
appropriate care and meeting the required performance targets via the
TC.
• Idealists enthusiastically embraced the broader vision and underlying
philosophy of TCs such as the ‘modernisation agenda’ of professional
reform and re-engineered patient pathways.
• Sceptics viewed TCs as transient fads or, worse, as risky endeavours, and
they therefore resisted top-down attempts at change. They urged caution
and tried to temper the extremes of idealism or opportunism. Through
these perspectives, powerful players in each site interacted to shape the
development of individual TCs.
In several of our sites, opportunists used the TCprogramme as a way to get
capital funding to finance projects they had already been hoping to
implement for some time. At Site G for example, a project group had wanted
to expand day surgery in their trust. Following the announcement of TC
funding and with some encouragement from the SHA, the project group
developed a bid for a TC mainly as a vehicle for the day surgery unit they had
thus far been unable to realise. Site B was another example where
opportunists seized the day, recognising that the TC Programme was a
chance not only to provide a new facility that would relieve the overstretched
hospital’s crippling bed shortages but also to refurbish a costly building, long
regarded as a millstone that was under-used because it was tied up in an
inappropriate trust facility. Establishing the TC in the building would resolve
these twin problems of an underused building and an overstretched inpatient
service. At Site A, the purchase of another hospital by the NHS was a chance
that the opportunists had already grabbed and which immediately formed the
basis of the TC when the programme was announced subsequently:
A little bit of it was opportunistic it’s fair to say, the hospital, just down the road
that had come onto the market. Splendid facilities and at a time when in terms
of capacity we were pretty tight it’s fair to say.
(Site A: senior manager, host trust)
The ‘pragmatic’ perspective was about the business of simply getting on with
delivering a good service. For pragmatists, while care delivery might well be
improved in line with the ideas enshrined in the modernisation ideal, the
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main intention was not to rethink practice but to streamline or otherwise
upgrade it. They recognised that the TC afforded an opportunity to do so, or
to be recognised as doing so, as the following quotes illustrate:
We’re starting to say to them, we’re going to shine, you always have done but
now the spotlight is on, so carry on doing what you’re doing in the way you’ve
done it and the excellent service you provide, but now people are going to
notice.
(Site E: nurse manager)
The TC gives me and people in this trust an ideal opportunity to do it properly,
to set new standards, to change communication and staff attitudes.
(Site C: middle manager)
But, as the second quotation suggests, that opportunity could easily spill over
into a more idealist frame of mind. In the case of Site B, there were many
pragmatists who used the innovation as a way to further develop services
they were already providing. But the TC also allowed a group of innovative
idealists to ride the wave of modernisation and push others, including the
pragmatists, towards radically new ways of working:
Someone said ‘essentially we’re moving [the existing day surgery unit], and I
said ‘no way, that’s not what we’re doing. What we’re doing is we’re moving
[that unit], but we’re recreating a different way of working and doing that so it
provides a great opportunity to do that. I think what it will do as well is a new
facility will encourage the shift around making day surgery happen, and I think
why we’ve got to do that is a lot around the booking scheduling agenda.
(Site B: senior manager)
It’s the future, isn’t it? Booking, day surgery, modernisation of pathways,
workforce development is all the way, that’s the development of day surgery
really. I treat the [TC] as the priority on my list because that’s where I intend to
go. In the next 10 years that is where day surgery is going, definitely.
(Site B: nurse manager)
This nurse manager and the middle manager quoted below, archetypal
idealists both, had their effect partly by running a training course on process-
mapping (getting staff collectively and systematically to rethink from first
principles the processes to which patients were subjected) which was led by
enthusiastic innovators associated with the TC. The course was opened up to
wide range of hospital staff, large numbers of whom attended and spread the
ideas. In this way the TC became a vehicle for redesigning the delivery of
care and engendering an important shift in mentality.
I have to say, and I like this modernisation. I enjoy going in and looking at how
people are doing things the same way, let’s get round a table and see how we
can do it better. I do like that.
(Site B: middle manager)
At Site E, a senior manager, who could well be classified in this context as an
idealist fully wedded to the ideology of modernisation and ‘transforming
patients’ experiences’, was enormously influential in establishing an
innovative TC:
I think there was a real want to change the way services were delivered here,
that was the project manager’s whole role – he wanted to provide something
very, very different – that was the future of health services and that’s what he
was pushing for.
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(Site E: senior manager)
Opportunism, pragmatism and idealism were not the only possible responses
to TCs at the local level. Some actors were more risk-averse, tempering the
plans of the idealists and opportunists, or possibly just more jaded about yet
more change in their NHS.
I have to say that I’ve only ever spoken to a few of the consultants there, and I
get told well, it’s a complete load of rubbish, it’s another bloody target we don’t
need and go away. And I’m quite sympathetic. I know it’s not easy, but at the
end of the day I have a job to do and it’s not my fault that this… you know, I’m
just here to do a job. If I get blamed for everything that the Government do that
the consultants don’t like.
(Site B: manager)
As one respondent scathingly told the interviewer when asked about the TC:
You come up with all these fuzzy words. I don’t quite understand… well it’s a
day case unit, isn’t it?... The trend is to identify within the whole morass of the
health service bits that can be cleaned, identified, counted, costed and get on
with that. Day surgery, treatment centres coming in, the cancer work being
centralised, not just because it’s a good idea clinically to have the expertise but
because it’s a way of dealing with it that is more uniform. The worry is what’s
left and how that’s going to be managed.
(Site B: hospital consultant).
At Site C this frustration with change was also located at the local level. A
senior manger reflected on the huge organisational changes implemented in
the previous few years and commented on change fatigue:
I think one of the comments that one comes across within the organisation is
that whilst people are up for the challenge, it’s something that yet again [that] is
new ... There’s also planning fatigue in that they’re only a year away from
having achieved a significant planning feat... [this] new treatment centre comes
swiftly on the back of the new acute hospital site and therefore people, to an
extent, are probably worn out .
(Site C: senior manager)
Sceptics often suspected that the rationale for TCs went beyond – or even
had little to do with – the philosophy of TCs as portrayed by, say, the
Modernisation Agency (Section 2), or as championed by the idealists. For
example, some sceptics saw the separation of emergency and elective care as
simply another unwanted organisational change imposed by the Department
of Health or as part of broader (party) political manoeuvring:
On one level I see it [the TC] as cutting down waiting lists, taking the workload
off other hospitals; on the other level I see it as a government initiative to get
elected at the next election.
(Site A: middle manager)
Sceptics were often concerned with the impact of the TC on other areas, such
as risk management or models of care delivery:
There are clearly great difficulties. Some trusts and consultants in those trusts
quite legitimately, in my view, feel that if they’ve seen a patient in outpatient,
investigated them and discussed an operation with them, it is very demoralising
to see that patient go up the road and have a stranger do their procedure.
[….]You have very un-joined-up patient care which may certainly crunch your
numbers but I think leads to consultant dissatisfaction, professional
dissatisfaction, poor morale and ultimately, I think, to poor human relations.
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(Site G: hospital consultant)
Within all the case study sites, the initial conditions that we described earlier
in this section allowed these four types of player to set about arguing the
case for and against developing a TC. A crucial part of those discussions was
a discussion of the potential reasons for having a TC at all. It is to these
motivating factors for opening a TC that we now turn in Section 4.
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Section 4 Taking up the challenge? The local motives for opening a treatment centre
Section 3 has outlined the internal and external milieus of our eight study
sites. These local contexts and relationships influenced and shaped not only
the decision whether or not to bid for a such a centre, but also the planning
processes that led to its opening, and the initial form taken by each of the
organisational innovations under study.
Our eight case study sites include some of the earliest ‘trailblazer’ TCs as well
as sites which were part of the later ‘first’ (which actually followed the
trailblazers), second and third waves of the national TC programme. The
process of bidding for a TC thus varied between the sites. Later sites typically
prepared an outline business case, and/or a strategic outline case to be
approved for funding, before going on to prepare a full business case for the
TC. There appears to have been an expectation from the Department of
Health that such plans would be developed in consultation with all the
relevant parts of the local health economy, in line with the usual planning
processes in the NHS. However it seems from our interviews with those
responsible for bidding for TCs and from other key players in the locality that
some of the earlier sites did not go through such rigorous, systematic
processes.
To some extent the planning process was closely linked to the initial
conditions described in Section 3, such as the existing relationships with
stakeholders like the SHAs and PCTs. But the variations in the planning and
evolution of the TCs were also shaped by the original motives for opening
such a unit.
Our fieldwork revealed a very wide variety of motivators leading up to the
decision to apply to establish a TC. These motivators helped shape the
resulting organisational innovation, and were played out in each site as the
local ‘pros’ and ‘cons’ were discussed and sometimes contested as the plans
for each TC took shape. What becomes clear is that this was never a case of a
local site taking an innovation clearly delineated by another agency – be that
the Department of Health, the Modernisation Agency, a pre-existing model of
a TC, or one local champion’s vision – and straightforwardly bringing it into
being. In none of the sites was there a simple process of implementing a
standard, existing innovation. As described by organisational researchers and
theorists (Kanter et al, 1992; Pettigrew, 1985; Van de Ven et al, 1999;
Helms-Mills, 2003) innovations undertake their own journeys, changing and
evolving as a wide range of organisational and other contingent forces mould
them into their eventual shapes: TCs were no exception.
In this section we describe the motive forces that led to the establishment of
our case study TCs, grouping them into three main categories, which we call
‘improving quality’, ‘improving quantity’ and ‘improving kudos’ (by which we
mean their standing in such matters as external profile, reputation, influence,
and income). These categories comprised a number of motivators such as the
desire to improve patient experience, to reform professional roles and
attitudes, to meet performance targets, or to improve organisational or
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personal standing. Many of these motive forces were at play at the same time
within a single site – sometimes pulling in the same direction, sometimes
opposing each other – since inevitably key actors and factions held differing
views and aspirations for their TC.
The interplay between the motivations to improve quantity, quality and kudos
was therefore difficult to discern. At Site H for example, it was clear that
something needed to change if the host organisation was to meet its
performance targets, and many believed that a TC was just such an
opportunity to improve the efficiency and the quality of care. Yet some
clinicians were arguing that it was clinically inappropriate to focus the work of
one of the hospitals entirely on elective care, a view seen by managers as
masking a reluctance by the consultants to countenance changes that might
negatively impact on their well-established working conditions and practices.
At Site F, motives related to improving quality (for example by modernising
care pathways) were even less visible, save perhaps as an ambition of a small
group of modernisation enthusiasts; the question of enhancing quality by
reforming professional roles and attitudes was certainly seen by most of the
managers to be a bridge too far. But improving the profile of the trust, in
particular consolidating the financial and political standing of the hospital,
was so much to the fore that opening a TC was an imperative. At Site B, on
the other hand, there were a number of influential people who were ready to
use the TC as a way of breaking the mould of traditional professional practice
and modernising care (improving quality) and moreover there was a clear and
almost unanimous agreement that bidding for a TC would be a pragmatic way
to help rectify failing performance levels such as waiting times (improving
quantity). The opportunity to solve a longstanding problem of how best to
utilise one part of the hospital premises and the need to ensure that the trust
continued to have a high profile in a planned redistribution of hospital
services across the region (improving kudos) also added to the urgency to
acquire funding for a TC. As all these examples show that the various motives
underlying the emergence and development of each TC, whether acting in
concert or in opposition to each other, differed not only between the sites but
also within them.
4.1 Improving quality
4.1.1 Patient care
There was little doubt that one of the main motivators in the local tussles
over TCs was the chance to improve the patient experience even, as we saw
in Section 3, for the sceptics. Some – in particular the idealists and
pragmatists – were fired up by the reports of good practice that were buzzing
around the clinical and managerial networks of the NHS and by the broader
drive towards modernisation of care processes that was given greater force by
the NHS Plan (Section 2). These developments all conspired to give at least
some of the key players in each of our sites the incentive to use the TC as a
means to do something innovative and exciting that they hoped would lead to
radical improvements in the delivery of elective care. Often this was
described, especially by enthusiasts, as ‘new ways of working’:
I think there’s something there about it being built around the patient….
ultimately for me, it’s about getting that standardised care so that every patient
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is getting the same sort of process. They’re getting a booked service, they’re not
going to get their operation cancelled, they’re home with their friends and family
that night. It’s those sorts of things. I think overall I feel it’s about reducing
dependency …..They’re not sick, they’re just well people with a problem, and I
think it’s about creating that culture of non-dependency. You come in and you
have a problem fixed and you go home, but I think still making the
improvements for staff though will be really important.
(Site B: senior manager)
It’s getting the clinics designed right so you’ve got the multi-professional clinics.
You now have the one-stop services for patients so that you’ve got a scoping
facility for instance for the urologists and gastro probably as well, type things.
Equally, it’s having appropriate radiology in there. .... People talk about these
treatment centres as being a sort of modern, new way of working and so on.
Can you characterise for me what you understand by that..? What I would like
it to be is that the patient can be booked in efficiently. I would like to have a
proper administration for the outpatients. I would like patients to come up and
go to a quality facility where they will get their bloods, breathing tests,
whatever tests they need and, for some patients, I would organise for them to
have the test before they see the doctor so that when they see the doctor
they’ve got the results, not come and see the doctor then go and have the tests
and come back some time later.
(Site B: senior hospital consultant and manager)
For me personally it is about all the other stuff that the national programme
sings about, really, and that, as I said, it’s not the catalyst but it’s the
opportunity to bring new people into post and it creates a new opportunity to
work differently and work more smartly… do we want to open Monday, nine to
five, with Saturdays, do we want to open term-time only and close for school
holidays. I need to be really convinced if we don’t go for the closing in school
holidays option because I just feel that it’s all very new. We know that people
for elective surgery tend not to want to come in over Christmas and the summer,
so why don’t we just make a bold decision and say, that’s what we’ll do, we’ll
close two weeks over Christmas, a week at Easter, close for two or three weeks
in the summer. Private hospitals do that.
(Site C: senior nurse manager)
At Site H the new ways of working were summarised as follows in the outline
business case:
At times of peak emergency demand… the requirements of emergency workload
take precedence over elective workload, and both day case activity and
inpatient elective work needs to be rescheduled. Apart from impacting upon the
trust’s performance in terms of activity and waiting times, such instances are
crucially distressing and disruptive for the patients concerned, and their family
and social/work relationships. There needs to be a greater protection for this
planned, elective workload to prevent these circumstances arising in the first
instance and the [diagnosis and treatment centre] provides that greater
protection by separating the ambulatory and short stay elective workload from
the emergency demand … the development of [diagnosis and treatment centres]
requires considerable re-engineering of standard processes and procedures
currently in use for dealing with patient referrals, appointments, admission
dates … it is recognised that that development of [diagnosis and treatment
centres] provides opportunities to strengthen and blur the interface between
primary and secondary care services.
(Site H: outline business case)
Site D anticipated similar benefits in patient care including improved
responsiveness through reduced waiting times; improved outcomes through
development of critical mass and sub-specialisation; greater predictability of
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process and care allowing greater levels of preparation and smoother
transfers; and the development of services closer to home, especially post-
acute rehabilitation. They also expected to achieve direct clinical benefits
such as better patient management, the development of specialist expertise
in an environment conducive to change, enhanced training opportunities,
better quality control and the more efficient use of consultant sessions.
Elsewhere, for example in Site F, some senior staff intended to modernise
services , even though this aspect was not necessarily a major feature of the
planned TC and, as the second quote below shows, was somewhat modest in
its ambitions:
I think the main developing factor was to try and bring in some additional
income to the trust and to join in a quite progressive modernisation theme. I
think the original idea was around using this site as a pilot for modernisation
that could then be rolled out trust wide and that hasn’t happened at all but
we’re hoping it will happen. There are a number of initiatives we want to look at
including skill mix reviews, just doing things differently, shortening the length
of stay, increasing the day case rate – so we want to explore a number of
initiatives that we can actually pilot on behalf of the rest of the trust and pre-
assessment is going to be the first such pilot.
(Site F: senior manager)
I do believe in what the [diagnosis and treatment centre] has to offer, its
innovative factors, my old modernisation thing. I like to be involved in new
ways of doing things. You know, many things are happening in the NHS that
should be done so much better than that. And, of course, the main philosophy
behind the [diagnosis and treatment centre] is actually putting the patient first.
Everything is built around that, not just paying lip service to it. If we can make
their health experience much better then it’s got to be a good thing … For
example, I’ve been trying to encourage one of our H grade sisters to be
innovative, and the latest thing we have been talking about is replacing the two
off-duties for the two wards with one person on at night working across the two
wards – being more creative within our establishment.
(Site F: senior manager)
The desire to modernise at this site might have been strengthened by the
need to survive in an increasingly competitive local health economy in which
other trusts, and even more so the private sector, were driving the need to
improve patient experience in order to attract referrals to the trust.
I think the real driver for change is going to be the independent sector much
more than the NHS treatment centres. I don’t think NHS treatment centres are
radical enough. When the independent sector are truly up and running I think
they will offer a truly different sort of treatment centre. I think the other thing
which shouldn’t be underestimated is the extent to which the threat of market
entrants from the independent sector galvanises NHS activity. Nationally all
sorts of things which are very difficult, if not impossible, within the NHS have
become possible because of the threat of independent competition.
(Site F: SHA manager)
But as we describe below (Section 4.3.1) any idealism of the modernisers at
Site F, even if it had been given extra impetus by the perceived threat of
increased competition, was tempered by concerns of a more pragmatic,
political nature.
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4.1.2 Reforming professional practices
The new ways of working had a number of spin-offs that some regarded as
more important than the actual change to the configuration of local services.
Foremost among these was the longstanding desire to reform the way
clinicians do their jobs – not only in terms of their day to day management of
patient care but also in the way they related to the organisation as a whole.
TCs that entailed new patient-focused care pathways were an innovation that
had the potential to alter fundamentally the roles, responsibilities and
autonomy of nurses and in particular doctors. For many in the health service
this seemed an opportunity to break down barriers, alter the range and
combination of skills of a whole new generation of nurses and professions
allied to medicine, and possibly even alter professional power-relations.
Perhaps above all some viewed it as a way of bringing the hospital
consultants to heel at least in the way that they organised their services, but
preferably also in the way they behaved as members of the organisation as a
whole (a matter of organisational citizenship). This attitude is illustrated in
the following three quotations:
Involving [the] independent sector has the knock on effect of breaking
consultants’ cartels – which is how [Site D] is often portrayed from outside.
(Site D: manager)
They’re not keen on changing practice, but we’ve got to move forward and
develop the service so that when we get the [TC], we’ll be prepared for it. So
what we’re doing is a lot of preparation work, so slowly we’re targeting each
different consultant. We’re picking a particular procedure, targeting the
consultant and saying well, we feel in our experience these patients are ready
to go home the same day, and if we put this, this and this in place, would you
be happy. What we’ve found is they are happy if you make changes slowly.
(Site B: senior hospital consultant and manager)
[The TC] is not exactly a Trojan horse, but more like an enabler to try out new
ways of working, different types of care pathways which in a non-threatening
way might introduce new flexible ways of working, including pre-booking of
patients (which some – but not many) consultants are very resistant to.
(Site B: manager)
As this last quotation shows, some sites were explicitly using the TC to reform
the way in which clinicians across the whole trust delivered services (and
indeed felt strongly that stand-alone TCs – like Site A and others nationally –
might fail to do this):
Look not only at the treatment centre, but its functional relation to the other
departments is quite useful to see because that will give you an impression of
the opportunities to look at how the patient pathway works from outpatients
through diagnostics through treatment centre through inpatients, and how
patients may flow through the whole. So, that leads us maybe in two years time
to this concept of the whole hospital treatment centre because so many things
are interrelated, and that’s the opportunity that this treatment centre probably
gives us.
(Site H: senior manager)
I think the treatment centre, because it’s a new build, it creates a new
opportunity. The trust has learnt from the fact that they built this new hospital,
we moved in, and we didn’t change our processes. We transferred old
processes into a new build. It was a huge job moving here. It’s easy to reflect
and want to do it differently but I think the learning has been that for the
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treatment centre we do want to try and do things differently.... So, it creates a
double set of challenges. It’s not about just making what happens in the
treatment centre right and best practice and leaving the activity in the general
hospital area behind. We’ve got to make both areas and move forward together.
(Site C: manager)
These views contrasted with the views, say, at Sites A, E and especially D
which saw their strength in trying to maintain as much separation as possible
from their host trust. They wished to introduce new ways of working that they
felt were impossible in what the TC visionaries saw as an irredeemably
hidebound host trust (see Section 3.2).
For some things it is appropriate for [the host trust] and the treatment centre to
stand alone. We don’t want to stand in the way of innovation because it is an
opportunity to be forward-thinking and do things differently.
(Site E: senior hospital consultant)
Site D based its ideas of professional reform on its direct links with a
surgicenter in the US, at which leading clinicians spent time learning the US
methods of care delivery, and with which the TC had a contract for team
building work and other advice.
Yeah, I went over in February, this year, to [the US site]. The main thing that
struck me was the whole culture over there – that everyone is very a flat
structure, not like it is with NHS. And it was really bringing that back and trying
to incorporate that [ethos] into here. And also mainly the pre-assessment and
pre-education lectures are fantastic and create a patient system like that –
which is something we’re trying to do here with two advanced practitioners for
pre-assessment here.
(Site D: senior hospital consultant)
The feeling among such converts was that such an approach to changing the
whole way in which professional care is organised could only be done away
from the main hospital, starting with a clean sheet as it were, and free of
close ties with established custom and practice.
TCs also provided – as an integral part of the prevailing modernisation
agenda – the opportunity to change the professional roles of clinicians other
than doctors. In particular, many TCs hoped to broaden the skills of nurses,
operating theatre staff, professions allied to medicine (for example
physiotherapists) and occasionally also radiographers. At Site G a senior
nurse manager described how they were looking at new ways of using
assistant practitioner roles and about moving nursing staff between the TC
and other areas to increase their skills and range of competencies. People at
other sites talked about other changes in skill mix:
I think new ways of working that I would like to see come in is that we would
work much more in the operating theatre with surgical assistants. I think we’ll
have to reorganise fairly radically how we run pre-assessment clinics and try to
involve junior medical staff.
(Site C: senior consultant)
We’ve increasingly got people able to order x-rays, who are extending the nurse
prescribing arrangements, the roles in theatres … they’re changing quite
significantly. We’re looking increasingly at practitioners in different areas to
take on the role of junior doctors. The health care assistants are taking on quite
a bit of the work of the qualified nurses, the nurses themselves are taking on
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doctors’ roles. We’ve got night nurse clinicians who do virtually everything that
the junior doctors can do so we’re making quite a lot of progress.
(Site B: senior manager)
I’d certainly still like to multi-skill the [TC]. I believe in multi-skilling and I
always have…. I think it could be far more efficient if we did that. If we got rid
of the, ‘I’m the scrub nurse and I’m the ward nurse.’
Interviewer: What steps are being taken to break down those barriers?
Well we have changed quite a few things where nurses go and work on the
ward and I say nurses – I use that as a generic term – and HCAs [health care
assistants] have certainly been brought in to do various tasks which they never
used to do before. I certainly wouldn’t want to see people say having an
untrained person either taking a theatre case or assisting the anaesthetist
because if things go wrong they can really go wrong and you need someone
who knows what you’re doing and what you’re up to and, equally, I think it’s a
quality issue. I’m not saying you can’t train people up to do things. I think you
can.
(Site B: senior hospital consultant and manager)
The question of how these new roles and arrangements such as clinical
assistants and nurse-led units were eventually developed – or not – will be
dealt with more fully in Section 6.
4.1.3 Promoting training and research
Although rarely mentioned at the start of the TC programme, training was to
become an issue once TCs had been established. (Various media and
professional groups voiced concerns about the independent sector TCs and
their impact on training [BMA, 2006a; Lane, 2005]; see also Section 7.2.3).
In the early days there were some who saw their TC as an opportunity for
training clinicians – an opportunity linked to some extent to the ideal of
changing clinician behaviour through the example of the new facility and its
new ways of working
More recently we’ve been able to hone in a little bit on what the training might
be and … what’s seeming to come to the fore is that maybe a lot of the
education provision is not going to be feeling-based, it’s attitude-based. It’s
behavioural-based. It’s getting people to think with a different mindset of, how
can we do it, rather than, it’s not possible to do it. So, that’s what’s parked at
the back of my mind that we’re going to have to do some work on but, as I say,
I’m waiting for more clarity about what that actually looks like.
(Site C: trainer)
Although rarely given as a motive for opening a TC, its potential to enable
more efficient training, and indeed research, was sometimes mentioned. This
is interesting given that one of the arguments against TCs was that as
factories for routine work they would militate against training and
development:
Interviewer: What do you see as the clinical opportunities offered by the
treatment centre?
Hospital consultant: I think it’s volume, really, and it’s the chance to do large
volumes of work and, hopefully, at a high quality. With that then one would
hope you’d get the added benefit of becoming even better in terms of research
and training. I think as a personal individual the possibility of doing more of the
particular work that you want to do so you can become more specialised.
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Interviewer: One of the critiques of the treatment centres is that many of them
aren’t going down the training research route but you see that quite differently.
Hospital consultant: Well, we do because if we, for example, wanted to do a
little trial comparing something against something, if you’re only doing 250
things a year, it’s actually quite hard often to show a statistical difference,
whereas if you’re bumping it up to 500 a year, then all of a sudden you’re
starting to get very large groups of patients that you can do things with. So, we
perceive this as an opportunity of doing high volumes and therefore being able
to do some meaningful research. Training, I think, is a more difficult issue
because one is always conscious of the fact that the model for a treatment
centre is really about volumes and so on but given the high volumes there is, I
think, still a possibility of training albeit one would have to think about how
that’s done in terms of it’s not a case of leaving the registrar to get on slowly
with a hip replacement but perhaps doing four in a day and he’s involved in a
little bit of each one so you don’t slow down the whole process terribly much
but at the same time he has done a bit of every operation. So, there is a chance
to do that.
(Site C: hospital consultant)
So, we could see that in the long run if the thing ever came to fruition it was
going to have an impact on medical training. And, the trusts were reasonably
concerned about the impact it would have had. And [Site A] was an extreme
example because they were going to put in all of their elective stuff which
meant there was no elective experience back at the ranch, which meant that in
the current regime the college and deanery would have stripped the posts out.
This is where we thought they were perhaps not really recognising the full
extent of the issue, they were saying ‘let the consultants come and bring their
juniors with them and they’ll get the experience that way’; which is okay for
[Site A] but back at the host hospital that would have left big holes in their rota.
(Site A: workforce confederation manager)
But with an eye to the future what we thought was, well, if we’re going to
operate that system, if we’re going to look at the rotations and use [Site A] as
one placement on the rotations we better put some more juniors in. So, what we
were able to do, to deal with the working time directive, most trusts in the end
adopted doctor labour solutions. So, we did take the opportunity to put more
recognised training days into the [regional] pool so that, should this situation
come to pass, where trusts actually were having a lot of elective work taken out
of them, which would impact on the juniors we would have the capacity to
restructure the rotations. Now, that’s why we’ve done it and that’s what’s at the
back of our minds. I think we’re a long way from persuading the STC {specialty
training committee} etc. that it needs to take a fundamentally different view of
the way they structure rotations. At the moment they don’t see the need to and I
know what will happen, once it actually starts to bite and they being to get
worried about what kind of experience people are actually getting in a particular
trust, then they’ll start thinking about these issues and they’ll begin to take it a
bit more seriously, which, for me is a little bit frustrating but that, I recognise is
life.
(Site A: workforce confederation manager)
4.1.4 Optimising local premises
There were various ways in which concerns about current facilities provided
the motivation to open a TC. These fell into three main categories: optimising
bed use; a chance to upgrade existing premises; and a way of paying for a
new building that was in any case needed.
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All three were apparent at Site G, where the trust saw the opportunity not
only to improve its bed management, but also upgrade a building, establish a
separate unit and moreover increase income in one fell swoop:
The whole idea that if you batch groups of patients and operative types
together, you can be much more efficient. Out of that came a proposal that this
void in our new building could very easily and quickly be converted into a state
of the art day case unit. We wanted part of that for our own work but there was
obviously a vacancy there [for outside work] and that’s what we did.
(Site G: hospital consultant and manager)
This desire led initially only to a stop-start discussion as various designs were
talked about, including a stand-alone facility. Some of the early key players
went out on fact finding trips to see how other hospitals did day care. They
came back with ideas and became agitators for getting a day care unit. The
hospital then received a windfall legacy from a local philanthropic source
which, after some wrangling with the local League of Friends, allowed the
building of an extension to the hospital. The trust decided – possibly
influenced by a chairman whose general philosophy was ‘let’s just get on and
do it’ – to build a two-storey ‘shell’ and fill it later. This proved decisive:
having an empty space that could become a day care unit was then a strong
enabling/motivating factor for the TC bid. The PCT were also keen to open
such a facility as a solution to an under-capacity problem, recognising the
opportunity to commission additional work from a day care unit. However the
catalyst for developing this idea into a TC was financial opportunism edged
with political expediency:
We tried various routes to do that, to get the funding, to get it off the ground,
and we eventually ended up with the support of the strategic health authority,
who had a bigger route, through the [diagnosis and treatment centre]
programme.
(Site G: senior manager)
The main precipitating factor came finally from higher up the NHS hierarchy:
At that time we then heard that the government for the first time started to talk
about overseas treatment teams, so that would have been in 2000. I quickly
spoke to a few people in the Department [of Health] and said to them, ‘is there
any money for this? If you want we’ve got a place for the overseas teams to
operate, no problem, but I need some capital as well, it’s the capital.’ And, I got
told there wasn’t capital. So, we put in a bid [for the TC]. Then I’m not quite sure
exactly how it happened in terms of the osmosis but they came back that while
we hadn’t got money for overseas treatment teams but that our bid had been
very well received because we could have this thing up and running quickly
and we could use these teams. And the government was going ahead and
wanted new treatment centres and they wanted them open tomorrow. … And,
at the same time as we had the crisis in [another local trust] … The conversation
I had with [a civil servant at the Department of Health] was quite bizarre. He
said, ‘I hear you can open a day case unit treatment centre quickly?’ I said, ‘Oh
yes, we’ve got the shell, we could do it.’ ‘How quickly could you do it?’ ‘How
quickly would you like it?’ Well, the Prime Minister wants it tomorrow to sort out
the [neighbouring trust] problem, he wants all these two-year waits sorted in 18
months.’ ‘In five-and-a-half months we’d probably do it if you give us the
money; two to two-and-a-half million, that’s what we need and you have the
treatment centre, I can open and we’ll bring the overseas teams in and we can
do it.
(Site G: senior manager II)
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The result of such a serendipitous but urgent melding of central and local
motives led to a precipitous and nerve-wracking deadline that was met with a
derring-do spirit by the whole team. But similar considerations also affected
other sites, if at a somewhat more leisurely pace.
At Site H the case for the TC to upgrade poor quality premises was explicit:
Apart from performance issues, the ENT [ear nose and throat] and
ophthalmology services are provided from the [host hospital] site … the smallest
and poorest quality site owned by the trust … this site is scheduled for closure
and disposal.
(Site H: outline business case)
But the fraught local politics tempered this case for new facilities with the
need for utmost caution to avoid the pitfalls that came from the factional
vying between the two hospitals that were being merged.
At Site C clinicians were complaining that inpatients, surgical day cases and
medical outliers were all jumbled together, making it difficult to protect day
case space and enable the day case unit to work efficiently. The TC was a way
of absorbing the inpatient load and enabling the effective ring-fencing of day
case work:
Since we’re moved here we’ve just been totally unable to run day surgery.
During the summer, okay, but just during the last winter the day surgery has
been filled up with inpatients.
(Site C: hospital consultant)
When we were preparing, really, for the move through to the new PFI [private
finance initiative] hospital the discussions had already started at the senior
management levels with regard to bidding for a treatment centre. I think there
were perceived to be a number of advantages locally in the trust and probably
the most obvious of which would have been the added capacity that the
treatment centre would bring and it was felt that this is probably going to be
very beneficial and I think everyone had realised that the PFI build that we had
got was probably going to be slightly too small for present demand and,
certainly, for our future demand.
(Site C: hospital consultant II)
It was a very similar story at Site G, where the initial motivation was not
about a TC but rather about slightly increasing the capacity of the day case
facilities. There had been a consensus within the trust that the hospital
needed a day care unit; one of the clinicians claimed to have spearheaded
this:
I was one of those consultants who, a year or two back [i.e. some three years
before the TC opened], perceived that we didn’t have a day care facility and
that a day care facility would be advantageous for all concerned and as such I
was one of the driving forces behind the call to expand in that area and I wrote
a number of notes and letters and argued the case that we should have a day
care unit.
(Site G: hospital consultant)
4.1.5 Improving staffing levels
The benefits of a TC in attracting good staff were also mentioned at a number
of our sites, either because the added work necessitated additional staff, or
because the new ways made it easier to attract good staff:
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This was a way of getting extra consultant staff and extra anaesthetists. Off
the back of the [diagnosis and treatment centre] we’ve made something like –
don’t quote me the exact figure – but 10 or 12 appointments. We’ve made three
or four in urology, three or four in orthopaedics, two in general surgery and
about three or four in anaesthetics. So we got a substantial increase in staff.
(Site F : senior hospital consultant and manager)
At Site C, where there was a history of difficulties in recruiting particular
types of staff such as theatre technicians and nurses, the development of the
TC was seen as feeding into a larger process of role redesign, which could
address skill (and staff) shortages. As a briefing paper presented at a
workforce planning meeting described:
Within [the hospital] we need to think bigger to maximise the effect that role
redesign has the potential to do. The danger with singular roles is that when
that person leaves there is nobody with the skills to replace them, especially
where the role was developed with a person in mind, rather than a service
requirement supported by competency based training. To have a bigger impact
on health care we need to look at developing new roles on a larger scale,
identifying competencies required and providing access to the training
requirements to support this. We need to do this with an understanding that
these new roles may become obsolete alongside existing roles in the future.
Role redesign should create a culture which will; challenge existing ways of
thinking, where the primary focus is on the patients perspective, where we
examine existing processes and eliminate those processes or steps which add
little value, therefore enabling us to address capacity issues and skills
shortages… This could be achieved by blending some different versions of
process thinking, re-engineering, total quality management and lean thinking
and then linking these into current challenges, workforce capacity, pay
modernisation and EU working time directives. Service improvements will then
find new kinds of workers to address staff shortages through the development
of new roles and the redesign of existing roles. It will impact on processes, job
roles, facilities, patient care, financial recovery and how we look at the future
deliverers of care within the health service.
(Site C: briefing paper for workforce meeting, prepared by seconded member of SHA)
At Site D the initial plans for the TC were that it would be a nurse-led unit.
Indeed this strong emergent identity of the centre, incorporating advanced
training and good prospects for career progression for nursing staff, was used
to sell the TC to prospective staff during the initial recruitment phase and
subsequent education of 20 advanced nurse practitioners:
Yeah, I think the big thing for me… (a) was it a brand new project and how often
do you get a chance to actually set something up from scratch? So that’s one
thing. But also having worked at the [neighbouring trust], resources were just
really, really bad. And the clinical nurse specialist was so frustrated because
she wanted to do so much, but her patients only just couldn’t do it, because she
didn’t have the resource. But here, at the brand new centre, it’s just a real
opportunity to be able to do so much more ... We’ve been fighting for
professional status for so long and to be able to take over what the doctors are
doing and to be at the forefront, delivering what nurses haven’t done before –
we’ve got fantastic nurses. And if you do speak to any new advanced
practitioners out here, they’ve also got the bug and they just think it’s great.
(Site D: senior manager)
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4.2 Improving quantity
4.2.1 Meeting performance targets
Often the senior managers of a trust were strongly driven to open a TC
because they saw it as a way to meet the NHS performance targets that were
becoming both increasingly important and progressively more challenging for
their trusts to meet. In fact, at all the sites the need to reduce waiting times
and waiting lists was a key motivation for opening a TC – and in this regard
their views as to the role of a TC did coincide with those of the Government.
As we saw in Section 2, the TC programme was explicitly aimed at not only
modernising care but reducing waiting times and thereby increasing access to
care, which had been a major manifesto pledge.
We will make sure that we improve the patient experience in hospitals. The
patient experience here is actually very good. What we need to do is make sure
we deliver on some of the time issues as well for them and manage the waiting
lists effectively.
(Site G: senior manager)
Often the trusts saw the potential for the new TC to reduce waiting lists as
being principally about increasing capacity – bed numbers – so as to increase
throughput:
We have a real problem in terms of capacity, long waiting lists, we only had
four theatres. We were expanding in terms of orthopaedics but the orthopaedic
surgeons couldn’t get the patients in because we didn’t have the capacity in
terms of theatres and beds. And even though we had a large elderly population
we were very poor in terms of the proportion done as day cases. I had a strong
feeling that the reason why we had a low percentage of day cases was because
of the ageing population. I also felt that once we had a dedicated day case unit
they could get some of those patients in as inpatients, that change would
happen, which in fact it did.
(Site G: senior manager )
The treatment centre, for us, is not a build that just increases our elective
capacity. What it does is increase our overall capacity.
(Site C: senior manager)
There was also a sense that increased capacity could also help other trusts
meet their waiting list targets – hence the intention of several of our sites to
take on some of the elective work of neighbouring trusts, known to be having
difficulties meeting these targets (see next section).
The TC could also help meet other targets. At Site B for example, the really
urgent performance problem was to reduce the unacceptable wait that
patients were having in the emergency department. This had become a real
concern for the hospital, and it was a consequence of there being insufficient
beds on the wards for emergency department patients to be admitted to. And
the shortage of inpatient beds was partly due to inefficient planning of
admissions and discharges of elective patients, who in turn were being
shuffled around the wards to try and make space for emergency patients. A
related problem was of course that elective patients would all too often be
cancelled because there was no bed into which they could be admitted. The
opening of a TC was an unmissable opportunity that allowed the hospital not
only to manage the elective patients more efficiently, but also provide short
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term space in which to move patients when they did not need emergency
care.
Site F was also motivated by the need to hit performance targets. As a major
teaching hospital it was embarrassed to be seen as failing on many of its key
targets. Some of the senior team felt that the TC, by increasing capacity and
patient flows, would help alleviate those problems. But as will be described
below, this was but one motivator among several, and coincided with the
desire to improve efficiency, attract more patients (and the income that
flowed with them) and remain politically ahead of the competition.
4.2.2 Improving provision of services across the locality
There was no doubt that the desirability of a TC was often increased when it
was linked to meeting the need for increased capacity across the whole of the
local health economy in order to improve access to services.
What the PCTs needed [was] to plan collectively to deliver the NHS Plan in
December 2005, and it was clear there was a shortfall in capacity. Particularly
[Site C] had identified a shortfall because of growing population, the need to
clear backlogs of waiting lists and so on, as per other health communities. And
because [Site C], the new [hospital] wasn’t actually open… for another couple of
months, this idea of building a treatment centre on the [Site C] site was mooted.
And then of course all the interim debates started about what should go in it,
what kind of services should it provide, and I think [the local] PCT from the
outset was clear that it needed to augment the existing elective capacity for the
population.
(Site C: local PCT senior manager)
What became very clear... was that there was a significant orthopaedic gap in
the health community that the ..main provider just was not going to be able to
fill. We looked at various options for delivering and additional activity, some
[approximately 700] cases for that year. One was to run waiting list initiatives
at that hospital, another was to purchase a mobile theatre [there] and try to
bring in locums. We looked further afield at that time. There wasn’t really
anywhere else that had [the necessary] capacity. We could have farmed it out
in various sort of rather piecemeal ways, but there was no real one solution,
and then [Site G] came forward and said actually this day case unit that’s not
being fully utilised, we might be able to do something [with the capacity there].
(Site G: PCT manager)
We were quite keen on the idea of getting our own waiting lists down, firstly
because we had our own problems with targets and here we were being given
all this extra capacity, and the second thing being that there was a general
feeling that if you got your waiting lists down then you could then attract
patients to come here simply because they wouldn’t have to wait so long to be
seen because we got the waiting lists down.
(Site F: senior hospital consultant/manager)
What is less clear, however, is the extent to which the estimates of population
need and the likely demand for the new TC were thoroughly analysed and
thought through. Indeed in retrospect it seems that they rarely if ever were.
Site A, for example, was partly designed to solve a pressing waiting list
problem for a major teaching hospital but it was also intended to reconfigure
the services for that particular specialty across the locality, providing a
specialist service across several trusts for patients with low co-morbidity.
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The board had started to think through a different model of offering particularly
surgical activity, in terms of the separating out. At the time, very much the
thinking was, you know, the high volume, low cost sort of stuff. And so that
was the initial idea – that here’s this hospital, we have pressure, in terms of our
elective capacity, wouldn’t it be a good idea if we went down the line of the
American sort of surgicenter? So I think that was the thinking. … So I think it
was the coming together of an opportunity – the building was free – pressure on
the existing hospital trust, in terms of capacity and some doctors out there
started to think differently about how they could work. And I think probably the
product… the result of all of those three things coming together was the
acquisition of [Site A].
(Site A: senior manager, host trust)
The intention was to bring in large numbers of patients through the Patient
Choice scheme, but in fact within a year – by which time the numbers of beds
had been increased fourfold – the flow of patients was only half what had
been anticipated. This setback could partly be explained, some of our
respondents told us, because the planning assumptions about the type of
case mix that the TC would attract had been completely wrong.
[The planning by the host trust] wasn’t very sophisticated but then the time
frame was such that there wasn’t sufficient time in the process to do that in
terms of working it out and there were a couple of mistakes made. The main
mistake that was made was an assessment made of the lists which was
inaccurate in that 70 per cent of the cases would be minor… 30 per cent would
be [major]. In fact it turned out nearly to be the reverse.
(Site A: senior hospital manager)
A lot of [Site A’s] early problems were [that] they weren’t geared up to deal with
common co-morbidities.
(Site A: SHA manager)
Such inaccurate forecasting of the likely patient flows was not unusual, partly
because of the haste required in putting together the bids to open a TC within
the timescale of the TC programme, partly because of the lack of good
epidemiological information and analytic skills, and partly because some of
the planning teams were so enthusiastic to get the new facility and develop
the new ways of delivering care that they turned a blind eye to the lack of
supporting evidence about the viability of the likely patient flows and
casemix. Major decisions seemed sometimes to rest on an almost cursory
estimate of need:
We then investigated what we might reasonably do here and decided partly
because of the way the services were organised here and partly because it
married up with the waiting lists as published around London on the net that
we would do [three specialties]. So that was the mix of where the biggest
waiting lists were by specialty, and it suited us with the big [departments we
had in those specialties]. And so it worked out roughly about right.
(Site F: senior hospital consultant and manager)
In fact as things panned out, it wasn’t remotely right: just over two years
after it had opened the TC was forced to close through lack of patients.
Many single specialty and teaching hospital TCs were later accused of ‘cherry
picking’ cases and thereby affecting neighbouring trusts by leaving them with
the more complex patients. Site D was designed from the beginning to avoid
this and provide a sector-wide service. All the local organisations (trusts and
PCTs) that were involved in setting it up shared the same problem that
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inpatient waiting lists in that specialty were their main obstacle to achieving
the access targets in line with the NHS Plan. At the time (circa 2000) there
were not enough beds, theatre lists or surgeons to do all the work required.
Indeed the possibility of a centre to tackle that problem had been under
discussion over five years earlier.
It started really out of a couple of discussions that were held at the acute chief
executives’ forum at the strategic health authority. This is an informal meeting
of chief executives of acute trusts... It meets on a quarterly basis, and I used to
attend as a token representative of PCTs… And the NHS at the time was going
through some changes. The main changes it was going through was an
acceleration of activity, people were starting to talk about the acceleration of
activity associated with increasing the through-put of patients, increasing
capacity, getting the waiting lists down, etcetera, that sort of discussion. And it
was felt by a few trusts that this would be a good wheeze. It would be a good
wheeze for two reasons. It would be a good wheeze because it would actually
help with addressing the capacity issue, but it would also be a good wheeze
because it could prove to be a method of extracting resource from primary care
trusts, because it would have high political patronage, it would be in a position
whereby it wouldn’t be allowed to fail… Hence, there was logic in doing it,
whatever the rationale for the acute chief executives was. And for this reason, a
[...] steering group was set up of which I was a member… and the thing just
galloped away in the distance, and we’re left with what we have today, which
is a treatment centre.
(Site D: senior clinical manager, PCT)
The original aspiration behind this partnership model was to transfer all
elective patients in that specialty to the TC at Site D and thereby release
capacity for over 3000 general surgery operations at the base hospitals. This,
it was claimed in the publicity about the TC, would reduce waiting time to
meet NHS Plan targets; give better value for money than development of
additional capacity at the host trusts; improve access; and, not least by
separating off the elective theatre sessions, release bed and theatre capacity
at ‘base’ hospitals to pursue NHS Plan targets for general surgery.
The proposal for separating elective and emergency care at Site H originally
came out of a major review of service provision some five years earlier, and
subsequent deliberations, which had included a review of capital investments
across the local trusts and PCTs. This process, coupled with an inspirational
visit to the Ambulatory Care and Diagnostic Centre, led to the realisation that
there was now – with the TC programme – an opportunity to meet the notion
of separating emergency and elective care and to improve capacity as set out
in the NHS Plan. So despite the host trust’s initial reluctance to have any
explicit separation of planned and unplanned care across the two sites, the
eventual reorganisation of the trust that included the new TC at Site H took
due note of the need for appropriate provision across the sector. From then
on, many of the key local actors saw the development of the TC as being
driven mainly by this strategic reconfiguration – and consequent relocation –
of services across the locality.
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4.3 Improving kudos
4.3.1 Improving the profile of the organisation
At Site F the primary motive for a TC was always more a matter of increasing
efficiency/ productivity than qualitatively improving the patient experience.
Although Site F did have its share of influential modernising idealists, the
resultant direction was – as always – shaped by the ongoing interaction of a
number of differing views. Dominant was the desire to remain politically
ahead of the game and achieve the levels of performance required by the
government:
I would have thought there is a political drive from this trust to be at the
forefront of all things new, wonderful and modern and therefore this was a new
and wonderful modern thing and it was right for us to have it.
(Site F: senior hospital consultant/manager)
Question one, was it really set up initially to encourage new ways of working or
was it set up because, (a) maybe it was a political favourite at the time and (b)
because we thought we’d probably earn a bit of money on the back of doing
loads of other people’s work? Answer is probably that, not the innovation.
(Site F: senior manager)
Thus both the political incentive and the increased throughput coincided with
the strong drive to achieve more income through the increased activity that a
TC would bring. The need to increase activity overwhelmed even the most
modest attempts to modernise the care pathways, a point that may have
been disguised among the rhetoric of change, as this jaded champion of the
modernisation agenda wryly remarked:
If you were to have this conversation with any of the ‘management’ guys, they’ll
tell you the right gobbledygook, and tell you that we’re absolutely committed to
that [modernisation]. In reality, we’re so struggling to get the work and get
through it and stay afloat financially, that that’s not the agenda as I perceive it.
There are people beavering away to create that perception, and there are things
like pre-admission where it has been the sort of model… And there are the
other things… for example patients arriving on the day of surgery rather than
the day before for surgery. Those things have all been discussed as part of
developing things through the treatment centre and then on to elsewhere. But it
hasn’t. I don’t think that’s been as significant as it was at the outset but it really
was one of the main driving forces in justifying it and negotiating it because the
process of actually getting the work and doing it has been so difficult. We’ve
been crawling in mud… It seems to me that the perception is, if you paint it as a
modernising thing that’s good, therefore that’s what will be done.
(Site F: senior hospital consultant and manager)
In short, the main motives at this high profile trust seemed to be a
combination of a felt need to remain in the ‘good books’ of the Department of
Health, the Government and the media – for example by getting waiting lists
down and being seen to be engaging in the spirit of the modernisation effort –
at the same time increasing activity and income so as to survive financially.
Several sites that were less overtly entrepreneurial, such as Sites C, E and G,
also saw the potential for bringing in elective work from beyond their
immediate area and thus boost the financial state and the reputation of their
trust.
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It was felt as well that it would helpful in terms of bringing in outside work and
to also bring in funding and would improve the whole strength of the services
that we were providing in elective surgery.
(Site C: hospital consultant)
This void in our new building could very easily and quickly be converted into a
state of the art day case unit. We wanted part of that for our own work but
there was obviously a vacancy there [for outside work] and that’s what we did..
(Site G: hospital consultant/manager)
Site E was in little doubt as to the benefits that would accrue from opening a
TC following the political furore over the earlier hospital closure at that site.
The chance of attracting patients from afar, while a nice bonus, was a side
issue. Several interviewees at the start of the research suggested that the TC
was a way of regenerating the hospital site and its reputation by drawing
more elective surgery back to the town (the unit already had a day surgery
suite):
We’re putting [Site E] on the map, really, for treatment centre work... and with
the treatment centre hopefully lifting the profile of [Site E] and what’s here, it
might settle down and sort itself out.
(Site E: nurse manager)
We’re starting to say to them, we’re going to shine, you always have done but
now the spotlight is on, so carry on doing what you’re doing in the way you’ve
done it and the excellent service you provide, but now people are going to
notice.
(Site E: Nurse manager)
However there were some fears that the local community saw the TC as a
replacement hospital and not a TC.
The closure of the hospital is in the background the whole time when you’re
looking at the treatment centre and it’s one of the reasons why I’m very keen
that we stop calling it a hospital. It’s an interesting debate because at the
moment if you look at the road signs they all say ‘[Site E] hospital.’ They don’t
say ‘treatment centre’ and we are going to change that... They need to say
‘treatment centre’ or ‘minor injury unit’ because that’s what it is but it isn’t a
hospital anymore.
(Site E: clinician manager)
Six months later, all road signs read ‘Treatment Centre’. However, during a
round of final interviews two years later, a new senior manager confirmed
some of the earlier interviewees’ views:
I think it was wrapped up in the politics of the area – the downgrading of the
hospital – I think there was an opportunity there that was taken which was
based on politically astute reasoning. But activity was still happening on this
site so you weren’t looking at putting something completely new in; you were
looking at a rebuild…. I think the rest of the trust thought that it was a way of
extending the hospital and it wasn’t a treatment centre in the true sense of the
word… [The local people] wanted a hospital back and this was as close at they
could get. The local MP still argues (for) flashing blue lights back on this site.
(Site E: senior manager)
Finally, sometimes the motivation was simply to try to be among the best.
For example, fieldnotes from a discussion with a senior consultant/manager
at Site C report him saying: ‘[The] originators wanted a wonderful TC and for
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[Site C] to be seen as good in the TC world.’ This view was also apparent at
Site G:
We wanted to use all the ideas that were being put forward, we wanted to think
of anything that would hold [Site G] up as being a good example for everything.
I wanted people to enjoy working there, I wanted consultants from other trusts
to want to come back and I wanted patients more than anything to say that was
a fabulous experience.
(Site G: senior nurse manager)
4.3.2 Realising personal ambition or vision
It was not always easy to distinguish individual enthusiasm motivated by an
idealistic vision from that which was due more to corporate loyalty (wanting
one’s trust to be the best) or even to personal ambition. However it was
possible to perceive all of these drivers playing their part as we heard about
people’s views and involvements in pushing for the establishment of a TC. At
Site E, for example, much of the success was widely attributed to the project
manager who was brought in as a champion of the TC concept, bringing with
him experience and a clear vision to a project that until then had been fired
mainly by the pragmatic and opportunist desire to replace lost local hospital
services (see Section 3.1). Adding his idealist view that ‘the ethos of the TC is
not around the building, it is around care delivery’ emphasised the idea that
the TC was about innovative approaches to the delivery of care, of improving
local health, and of supporting the health economy by offering increased and
more efficient and effective capacity not only locally but further afield. His
success in realising that vision made the TC a showcase for the programme as
a whole as well as for the local SHA and region. This allowed the TC to be
treated as almost a separate independent organisation, which fulfilled the
ambitions of its senior managers and allowed them the freedom to develop
the centre more or less as they wished, to establish links with a wider
commissioning network and to make deals with the private sector treatment
centres, and so on: in short to operate the TC almost as a hospital in its own
right. But at the same time it also gave the individual who had been at the
centre of it all the opportunity to move on to a senior position in the private
sector.
Our sample sites included examples of ‘turf battles’ where as is so often the
case, it is difficult to distinguish whether the victories and defeats – which did
so much to shape the configuration of the TCs – were personal, ideological or
professional. In the following example, the fundamental question of
separating elective from emergency services seems to have been at stake,
but paradoxically this is seen as being at odds with the shift in ideology of
‘modernised’ care provision, and bound up in the speaker’s mind with the
reallocation of personal power:
Anyway, so at this time out, [M] presented a version of what I had produced but
it wasn’t the same and it wasn’t as good, I didn’t think, and [K] presented his
concept of planned and unplanned, which of course is not unheard of and has
been established in other places. Essentially the group were asked which they
preferred and they went for the planned unplanned model. So then [M] went
away and worked out and divvied up all the jobs and of course that didn’t
really leave my job in there anywhere. So basically there was a structure that
was a management structure, planned/unplanned with all the other bits like
facilities and what have you still there, no director of modernisation, in fact no
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modernisation anywhere in sight, which as I said, that was something that
really troubles me, and the treatment centre was obviously part of [K’s] empire.
(Manager)
Sometimes wider political forces dictated a particular approach to thinking
about the TC in the local context. For example at Site C the arguments over
the private finance intiative that lingered on from the recent new hospital
build (and followed though the TC build) resulted in the management team
having to respond to pressure both from central government and the trade
unions. They felt strongly the constraint of being between a rock and hard
place: the government was pressing for a success story in time for the
election, while the unions were using the TC as a stick with which to beat the
private finance initiative.
4.4 Summary
As this section has shown, the local organisations that took up the challenge
of establishing a TC did so for a wide variety of reasons. The motivations to
open a TC were, as we have suggested, often rooted in local history and
context (for example the ‘need’ for a day care unit, finding a use for a
recently-acquired former private hospital and so on) and to some extent
these factors were unique to each site. However there are common features.
Firstly, the people. There is a strong sense that the decision to open a TC was
dependent on the resolution of a number of often conflicting views (which we
have referred to as contests of meaning) between different individuals or
groups within organisations. It is clear that while initially there was a strong
role for opportunists in getting the idea off the ground, in the subsequent
stages the particular ‘version’ of a TC taken up by the organisation was
developed out of the ongoing struggles between opportunists, idealists,
pragmatists and sceptics.
A second, unifying thread to be found in the varied reasons why these sites
developed TCs is the sense that they wanted to improve – to ‘improve quality’
to ‘improve quantity’ and/or to ‘improve kudos’. In improving quality some
sites prioritised patient- focused approaches to care or ‘modernising’ patient
processes. This included such things as the fundamental reform of traditional
clinical practices and transformations in skill-mix. In improving quantity the
case studies were hoping to increase capacity, throughput and activity, and in
this they were tightly coupled to an agenda set down by the Department of
Health, which (Section 2) was concerned with reducing waiting times and
increasing activity. In improving kudos for the organisation the sites were
hoping their TC would make the organisation more competitive (or at the very
least to prevent them falling behind and becoming uncompetitive). Some
sites also used ties with external stakeholders (SHAs or higher up the
Modernisation Agency or Department of Health) to improve the profile of the
wider trust (or key personnel within it). This is evidenced in the swift
departure of several of the enthusiasts (often also ‘opportunists’, also in their
career paths) once the TC was secured.
The decision to apply for TC funding inevitably resulted from contests of
meaning, and as described in Section 3, these were clearly influenced by key
players who were themselves subject to pressures from the internal and
external milieus. For example there may have been – and usually were –
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idealists who saw the TC as a chance to improve patient care. But there were
nearly always sceptics who saw it as yet another fad, opportunists who
wanted to grab the funding to develop a new service that was in any case
much needed, and pragmatists who wanted to do whatever seemed most
likely to improve the service with minimum fuss. Even where there was
consensus among those with the power to make the final decision, there were
always discrepancies about their underlying motivations, rationales and
intended outcomes.
Most of our sample sites had key actors who were motivated by one or more
of the above rationales for opening a TC. Our interview data reflected
disparate views and biases: for example whether interviewees told us that the
main motive had been principally to improve quality of care or to improve the
achievement of performance targets would depend upon which side of the
arguments they had been on. But it was possible to discern from the many
sources what the balance had been between the various viewpoints and how
the decision to go ahead with the TC had come about – not least because
many interviewees recognised that there had been a range of views. It would
be a mistake, therefore, to suggest that the organisation was motivated by a
given factor to set up a TC: rather there would be a certain configuration of
views that led to an evolving and constantly negotiated clusters of decisions
that gradually emerged as something (at least) approaching some of their
initial visions of a TC.
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Section 5 Environment and influence: the wider policy context surrounding treatment centres
5.1 The policy context since 1997
The origins and history of TCs have already been described in detail in
Section 2 of this report. To summarise, the official start of the current TC
initiative was a Government White Paper The NHS Plan (Department of
Health, 2000a) which promised ‘a radical new kind of service’ (Department of
Health, 2001). The dominant policy context for TCs was the ‘war on waiting
lists’, the main enemy being perceived as insufficient capacity within the
system. Harrison and Appleby (2005) suggest that the policies the
Government has adopted in its ‘war on waiting’ have fallen into three phases
since 1997. Together these phases set the overall policy context for TCs
during our period of research:
Phase 1 (1997-2000): during this phase the Government focused on reducing
the number of people waiting rather than reducing the time of waiting
Phase 2 (2000-2004): increased investment and targets accompanied by a
wide range of policies to help transform the way that elective care is
provided. The government introduced a number of ideas and programmes
aimed at increasing supply within the health service, including:
• treatment centres
• day surgery
• the NHS Modernisation Agency
• specialty programmes (for example orthopaedics and ophthalmology)
• patient choice.
The Government also:
• supported the development of new services in community settings
• set targets for increasing the overall number of hospital beds
• introduced a star-rating system to provide a measure of trusts’ overall
performance (five out of nine ‘key targets’ were related to waiting).
Phase 3 (2005-2008 and beyond): in 2004 the government announced a new
target for the NHS, that by 2008 no one should wait longer than 18 weeks
from referral by a GP to hospital treatment. The target was to be helped by:
• extra capacity in the independent sector, which was beginning to become
available and was set to increase
• the Government agreeing, in early 2005, to £3bn worth of contracts with
the independent sector to overcome shortfalls in diagnostic capacity.
At the same time as helping cut waiting times, TCs (both in the NHS and in
the independent sector) are intended to support other parallel initiatives such
as improving patient access and choice, and the electronic booking of
appointments and operations. Harrison and Appleby suggest that:
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If all the policies in place by the middle of 2005 work in line with government
expectations, the NHS elective care system will shortly be transformed from the
‘command economy’ of the first two phases into a quasi-market economy.
Hospital trusts will be put under unprecedented pressure from patients
exercising choice (and taking the finance for their treatment elsewhere), other
trusts offering quicker access and the private sector potentially removing
business out of the NHS altogether.
(2005; p.xv)’
Beyond this, the development of TCs is also linked with wider moves to
reconfigure acute treatment services through shortening hospital stay,
‘downsizing’ hospitals, redrawing boundaries between primary and secondary
care, and re-engineering delivery processes.
As discussed in Section 2, TCs were designated one of the main vehicles for
implementing the challenging reform programme sought by the government
in the NHS Plan. Significantly for our case study sites this programme
included opening up the health care market to the independent sector in the
interest of expanding patient choice (and thereby ‘contestability’ – otherwise
known as competition). Section 6 will explore the specific impact these
various policy developments had in our eight case study sites and how our
sites responded to the resulting challenges. Here, we seek to summarise the
wider policy context in which the eight TCs we have been studying have been
operating.
The remainder of this section describes in general terms the significant policy
documents and key events which have impacted on TCs during the period of
our research and then provides an overview of three of the most influential
national policy initiatives that have been shaping the ongoing development of
TCs in the NHS, namely independent sector TCs, Patient Choice and Payment
by Results. We then report on the formation and functioning of NHS Elect – in
part a response to these drivers – before concluding with a discussion of the
wider policy context and how it has impacted in general terms on TCs.
5.1.1 Policy documents and key events
During the period under study the Department of Health provided a broad
strategy for the NHS through several major policy documents. It then set
national performance targets and introduced initiatives to help meet those
targets. We briefly summarise these documents below.
In April 2002, the publication of Shifting the Balance of Power (Department of
Health, 2002c) confirmed the abolition of health authorities and regional
offices, and the creation of PCTs. At the same time, 28 new SHAs replaced
the former health authorities and took on a strategic role in improving local
health services. Immediately after their establishment the Department of
Health asked all SHAs to identify any anticipated gaps in their capacity
needed to meet the 2005 waiting time targets. Harrison and Appleby (2005)
report that SHAs were asked to provide both estimates of what the NHS could
realistically do and their expected purchase of care from the private sector,
including overseas sources, and that this was the first time such an exercise
had been attempted across the NHS as a whole. In the same month
Delivering the NHS Plan: Next steps on investment, next steps on reform
(Department of Health, 2002b) referred directly to TCs as ‘fast-track surgery
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centres’and also stated that up to 150,000 operations might be purchased
from the independent sector.
In October of the same year, Reforming NHS Financial Flows: Introducing
Payment by Results (Department of Health, 2002a) laid out changes to how
money moved round the NHS, and set up incentives for hospitals to behave
more like businesses (see Section 5.4). Then, in December 2002 Growing
Capacity: Independent sector diagnosis and treatment centres was also
published (Department of Health, 2002d) providing the ‘background and
plans for diagnosis and treatment centres and highlights the role of the
independent sector in the diagnosis and treatment centre programme’. This
signalled the beginning of the first wave independent sector TC procurement
exercise discussed in the following section. In October 2003, the word
‘diagnosis’ was dropped from the term ‘diagnosis and treatment centres’ and
both NHS and independent sector treatment centres were referred to just as
‘treatment centres’ (TCs). According to the Department of Health (2003b),
the change coincided with a significant new phase of development, providing
‘a simpler name for the public and for patients’ at a key time. It did not
ostensibly reflect ‘any change in the core characteristics of schemes, or the
overall objectives of the programme’.
In January 2005, the Department of Health published Treatment Centres:
Delivering faster, quality care and choice for NHS patients (Department of
Health, 2005c). This update on progress with the TC programme explicitly
tied TCs in to delivering the new target announced in the NHS Improvement
Plan (Department of Health, 2004c) – the follow up to The NHS Plan
(Department of Health, 2000a) – of ensuring that by 2008 NHS patients wait
no longer than 18 weeks from GP referral to treatment. This report also
announced that the Department of Health was proposing to establish five
‘centres of innovation and training in short-stay elective care’.
5.2 Independent sector treatment centres
An important part of the TC initiative has been the contracting of independent
sector companies to provide services for the NHS, including employing clinical
staff. In 2006 the Department of Health’s commercial director outlined the
three principal objectives of the independent sector TC programme
(Department of Health, 2006a), namely to increase the capacity available to
treat NHS patients, to offer patients a choice over where they are treated and
to stimulate innovation in the provision of health care. Independent sector
TCs are, however just one part of a wider concordat with the independent
sector, first announced in the NHS Plan and published a few months later as
For the Benefit of Patients (Department of Health, 2000b). Then, in December
2002, the Department of Health published guidance for independent sector
TCs and the first wave was launched comprising a planned 177,000
procedures per annum over five years at a cost of £350m per annum (total
cost £1.737bn). This first wave procurement was focused on cataracts,
orthopaedics and day case work. In the same month the first public-private
partnership TC began treating patients at Redhill, Surrey. In much the same
way that the Central Middlesex Hospital’s Ambulatory Care and Diagnostic
Centre predated the advent of NHS-run TCs (see Section 2), this centre
predated the national procurement of independent sector TCs.
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5.2.1 First wave procurement: 2003
In May 2003, the Government announced that 250,000 finished consultant
episodes (FCEs) – just under eight per cent of the total activity in the NHS –
would take place in the independent sector by the end of 2005. On this scale,
this first wave of independent sector TC procurement appeared to pose little
threat to NHS services, and this was reflected by rhetoric that presented
independent sector TCs as a ‘pragmatic response that did not threaten the
NHS’s long-term role as a provider’ (Carvel, 2005). The words of the then
Secretary of State for Health were reassuring in this regard:
Patients will continue to choose NHS hospitals for most acute care, so for the
foreseeable future NHS providers are likely to continue to deliver most health
services. However, there also needs to be a greater plurality of provision – to
expand capacity fast, to stimulate improvements.
(Reid, 2005; p.10)
In short, the NHS was declared secure, while choice, capacity, quality and
service were said to be open to significant improvement.
These first wave independent sector TCs were defended on the grounds of
offering an efficient and rapid response to NHS capacity constraints and the
perceived inability of the NHS to expand sufficiently in order for government
targets on patient access to be met within the timescales set. Also, by
drawing on overseas expertise and trained professionals (which also ensured
that these clinicians would not have conflicts of interest about their own
private practice (Stevens, 2005), ‘additionality’ of publicly-funded capacity
could be achieved as well as providing the catalyst for wider changes in what,
up until now had been perceived as a (clinically) protectionist market:
We are going through a huge process of change where we are encouraging
people within the NHS to break down artificial demarcations. That is a process
we have seen before in many other industries in order to get better value for the
patient and, at the same time, outside, as well as inside, the NHS we are using
the power of the NHS in purchasing to break what some people would
previously describe as a monopoly cartel or a closed shop caused by a tight
control of supply and an encouragement for huge demand.
(Reid, 2004)
In September 2003 the Department of Health announced preferred bidders
for the first wave independent sector TCs and the following month the first
purely independent sector TC commenced services to NHS patients.
In May 2004 the Department of Health announced two supplementary
contracts with the private sector to focus on mainly orthopaedic procedures,
which had significant implications for some of our case study sites (see
Section 6). These schemes, known as G-Supp (General Supplementary) were
intended to enable primary care practices to purchase operations from the
private sector for NHS patients. At the time of writing G-Supp has had two
phases. The value of G-Supp 2 was £54m and work was procured by the
Department of Health under its new purchasing arm, the Commercial
Directorate.
By October 2004, one fixed and two mobile independent sector TCs were fully
operational and interim services were being provided on three further sites.
At the same time, the 2003 target figure of 250,000 FCEs in the independent
sector was doubled to 500,000 (15 per cent) by 2008 by means of a second
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wave of independent sector TC procurement (see below). Attitudes to
independent sector TCs began to harden. While there remained almost
universal agreement on the principle of separating elective and emergency
care (which underpins both the NHS and independent sector TC
programmes), far from wishing to enter into partnership, many staff in NHS-
run TCs including those in our own study began to show increasing hostility
towards the independent sector TCs:
More and more money is being poured into the health service… an awful lot of it
is just going down routes that are absolutely a total waste of money … I’m a
great believer in NHS treatment centres but I’m blowed if I can see why we
should be paying some entrepreneur in Dorset to turn a stately home into a
hospital, make money for himself and his investors and at the end of it all what
has the NHS got? Absolutely nothing. Probably some fairly dubious results from
the surgery and nothing left behind.
(Site F: hospital consultant)
5.2.2 Second wave procurement: 2005
In March 2005 the second phase of the independent sector TC procurement
was launched comprising both elective and diagnostic activity. Up to 250,000
elective procedures per annum over five years were to be procured plus the
creation of an ‘extended choice network’ of an additional 150,000 ad hoc
procedures per year (Department of Health, 2006). The cost was estimated at
£550m per annum (again for five years and at a total cost of £2.5bn plus
£175-200m per annum for the Patient Choice network). This procurement
also included two million additional diagnostic procedures per annum (£1bn
over five years) including boosting MRI capacity by 15 per cent and
employing more radiologists to deliver over 630,000 (non-urgent) additional
MRI scans via 12 mobile units. In addition, as Harrison and Appleby (2005;
p.45) suggest, ‘these contracts provide for massive increases in capacity –
about one-third in the case of computerised tomography scans and 60 per
cent in the case of endoscopies’.
Around this time (as evidenced by contemporary national surveys and
corroborated by our own research) many NHS staff began to see independent
sector TCs as privileged to such an extent by the Government that they now
threatened to undermine their own TCs’ long-term survival. For example, a
survey of acute trust chief executives included an assessment of the impact
that independent sector TCs were having on existing NHS services including
TCs: 77 per cent of respondents said that independent sector TCs have
implications for ‘existing elective work’ – particularly orthopaedics – and 25
per cent said they had implications for NHS-run TCs. The accompanying
survey of PCT chief executives reported that in 10 per cent of them over 50
per cent of the extra capacity purchased from the independent sector TCs was
not actually being used (Health Services Journal, 2005b). This growing feeling
of unease was further fuelled by Department of Health pronouncements to the
effect that the second wave was also about introducing ‘contestability’, that is
making NHS hospitals compete with one another and the private sector. As
one chief executive told an NHS confederation conference:
In terms of surgical centres. I don’t think we have overcapacity now and I
presume they are talking more about [the situation] when new centres come on
line... We need more capacity so we can offer choice and there is some
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contestability. If everything is operating at 100 per cent that is stultifying. We
need enough dynamicism (sic) to allow for some contestability.
(Health Services Journal, 2004)
The then Secretary of State for Health’s response to those who claimed the
increasing role of the independent sector was a form of ‘privatisation by the
back door’ was to reframe the issues in the language of equality and fairness,
while reiterating government commitment to the founding principles of the
NHS:
To those who have misgivings about it, I say two things: firstly, I will protect the
founding principle of the NHS of equal access to health care provided free at the
point of need … and the second is I will never apologise for the extending to the
mass of working people the privileges that have been monopolised only by the
well-heeled and well-connected since time immemorial. Why on earth would we
not be proud of extending that degree of information and power?
(Reid, 2005b)
Nonetheless, there are indications that the increasing role of the private
sector in TCs exemplifies a more general redrawing of the boundaries
between public and private sector that is a (controversial) part of current
government policy. For example, in south-west Oxfordshire the PCT was
refused the right to withdraw from a cataract surgery contract with an
independent sector TC when the PCT realised damage might be done to the
viability of the NHS’s Oxford eye hospital (Carvel, 2005). The volume
guarantees given to the independent sector TC in Oxfordshire – indeed all
independent sector TCs – seem to conflict with the Choose and Book policy
(see Section 5.3) being rolled out across the NHS. As the Health Services
Journal put it:
[Independent sector] TCs will be made artificially busy either simply by
channelling any growth towards the private sector or because of the failure of
NHS organisations operating under a more onerous financial regime. In either
case, this is hardly the pluralistic market championed by the government in
which patients shape provision by choosing on the basis of quality and
timeliness of care.
(Health Services Journal, 2005)
A second anecdotal example comes from Trent and South Yorkshire where
GPs from 28 PCTs were encouraged to make more use of the local
independent sector TC for orthopaedic surgery run by South African Care UK
Afrox Healthcare (which had a £98m five-year contract for more than 5000
operations). However, take up was reportedly slow as patients continued to
opt to go to the large NHS hospitals in Nottingham partly (a) because their
GPs knew the consultants there, and (b) the NHS hospitals were easier to
reach by public transport. Newspaper reports (see for example Revill and
Hinsliff, 2005) suggested that this lack of take up of independent sector TC
capacity had cost the local PCTs £2.3m in the previous year (equivalent to
400 hip and knee replacements) .
The BMA suggested that independent sector TCs were detrimental to local
health services, accusing the centres of depriving hospitals of resources and
patients. In a BMA survey of NHS clinical directors, 68 per cent of
respondents had said that independent sector TCs had had a negative effect
on the facilities provided by their trust (BMA, 2006b). One example cited was
of Southampton University Hospitals NHS Trust closing an orthopaedic ward
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because it claimed that much of its work had been taken over by Capio, a
Swedish-owned company based in Salisbury.
Our own research revealed similar perceptions that, directly or indirectly,
financial damage was being done to the NHS, and not just by the independent
sector TC programme. For example, a senior manager from a health economy
that contained one of our case sites described the effects of top-slicing PCT
budgets to fund a TC in the NHS:
It has drained I would say approaching £100m from the sector, and I’m a chief
exec of a PCT with a significant financial deficit. It’s a great shame, all this,
because certainly having an elective orthopaedic hospital could radically
change things for the better in orthopaedics, both for the patients, for the staff,
training – everything. So I think it’s a real missed opportunity. I don’t know
whose decision it was. If it was a politician’s decision, it’s almost forgivable. If it
was a senior manager’s decision, it’s outrageous because it has cost this sector
£100m.
(PCT senior manager)
All these examples offer somewhat different perspectives on the
government’s commitment to what Currie and Brown (2003; cited in Hoque et
al, 2004) have termed the introduction of a system of ‘entrepreneurial
governance’ So, from professional magazines like the Health Services Journal
– which devoted the first five pages of one edition to the topic – to
widespread coverage in the national press, and onto professional bodies such
as the BMA – with its warning of the imminent destabilisation of NHS hospital
economies – it is clear that independent sector TCs have stirred up an ants’
nest of issues for debate. Indeed, commentators have suggested that ‘no
other issue among the avalanche of reform which has hit the NHS in the last
five years has caused such consternation among senior health service
managers’. (Health Services Journal, 2005; p.3).
On the other hand, advocates of independent sector TCs and Patient Choice
(see Section 5.3) have fought just as hard for their corner, arguing that
independent sector TCs will raise standards and improve both access and
choice for patients. Contrary to the examples described above, proponents of
the independent sector TC programme argue that patient satisfaction is
running at over 94 per cent, that value for money has been achieved by using
bulk buying to reduce what the NHS used to spend per case on independent
sector activity and that clinical quality is driven upwards through high
standards and key performance indicators (Department of Health, 2006a). A
new body representing 11 independent health care organisations working
with the NHS has been established, in part – reportedly – to combat the bad
publicity over plans to expand the network of independent sector TCs (British
Medical Journal, 2006).
Nonetheless, as revealed in our research there are inherent and inevitable
tensions between the strategy of devolved power as evidenced by foundation
trusts and practice-based commissioning, and the top-down implementation
that seems to surround independent sector TC procurement, and even to a
lesser extent the development of NHS-run TCs. This is discussed further in
Pope and Robert et al (2006).
Some in the TC study sites were bitter, believing that the Government had
become the masters and they the victims of double-talk while others simply
accepted this the way the NHS has always been run. At the very least there
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was confusion about the different versions of reality being presented.
Politicians took the view that capacity levels in the NHS were ‘about right’,
that any extra capacity that existed in TCs was a relatively small proportion of
overall NHS activity. For example, the Health Secretary told a House of
Commons select committee that:
The level of spare capacity in the NHS in England, for which I am responsible,
is… about nine thousand places, I think. That is out of seven million treatments
a year. Let us put it in perspective. That is out of seven million treatments in
and out of the secondary sector of the NHS.
(Reid, 2004)
Some practitioners working in our TC study sites vehemently disagreed,
claiming that ‘patients are not coming’, that their TCs were ‘running on
empty’, a problem that, not surprisingly, was said to have worsened since the
opening up of the market to independent sector TCs:
Here we are, we’ve got six theatres, we’ve got five wards, three have been
completely revamped, we've got this fabulous staff, we’ve got all these amazing
facilities, and we’ve only got 20 patients in the building... [The Government]
insist on pursuing this independent sector nonsense, and I think that’s what we
find so frustrating. I think from the Government’s point of view, they just say,
we've just got to increase the capacity, we’ve made this commitment to an
independent sector, 15 per cent or 20 per cent, or whatever, and everyone’s
work has got to go through the independent sector, and that’s the promise we’ve
made. Well, that’s fine, but then you are going to lose some NHS treatment
centres as a result, so they’ve got to decide somehow, how that’s going to work,
because you’re not going to be able to have it every way.
(Senior manager)
In January 2006 it was reported that 21 independent sector TC schemes were
open and a further 11 were to open over the next 18 months, and that over
250,000 patients had been either treated or received a diagnostic service
from the independent sector (Department of Health, 2006a). In 2006 it was
expected that independent sector TCs would treat a further 145,000 NHS
patients; despite this seemingly rapid expansion in independent sector
activity when fully rolled out independent sector TCs will account for less than
one per cent of the total NHS budget and only about 10 per cent of all
elective procedures. Independent sector TCs are said to ‘exist to challenge the
system and supply some additional capacity but they do not represent an end
to the NHS as we know it’ (Department of Health, ibid).
But then – just as this report was being completed in May 2006 – a decision
to cancel seven of the 24 planned local independent sector TCs (representing
some £550m of work per annum) was announced. The remaining 17 schemes
were delayed for up to a year. The reasons behind this sharp about-turn in
policy are discussed in Section 10.
5.3 Patient Choice
By the end of 2005, all NHS patients were to be offered a choice of four or
five alternative providers at the point of referral (that is, in the GP surgery),
which would include independent sector providers. NHS patients were to be
given wider choice by their GPs of where, when and how they are treated:
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The New Labour Government is creating a decentralised, personalised, and
publicly funded NHS, committed to patient preference and the extension of
choice ... We are promoting diverse forms of public ownership, public provision
and public management … We are empowering patients to play a bigger role in
choosing where and who provides them with their health service.
(Reid, 2005a)
As Harrison and Appleby (2005; p.29) state, there is little doubt that the
initial reason for introducing choice was to achieve a reduction in the number
of people waiting for six months or more. ‘Choice’ was introduced as a pilot
scheme for heart patients in 2002 and then the London Patient Choice Project
offered patients the chance of quicker treatment in areas such as
orthopaedics, and ear, nose and throat surgery. The project began with
cataract surgery in 2002 and was then extended in 2003 to cover other
specialties and was also piloted in other parts of England. (It is worth noting
that findings from an evaluation of the project suggest that although choice of
provider was popular among those waiting for elective treatment, patients
were less likely to opt for quicker treatment by an alternative provider if they
were older, if they had low education levels, if they had family commitments
and if their income was less than £10,000 per annum (Burge et al, 2005).
However, such a scenario is likely to be highly condition-specific. In the
coronary heart disease scheme, 50 per cent of patients who had been on the
waiting list for six months or more took up the option of going to an
alternative hospital to avoid a longer wait (Le Maistre et al, 2003).)
While the current emphasis on ‘choice’ is concerned with the emerging
models of organisation and management for the public services – also
described in somewhat dramatic terms by the then Secretary of State for
Health as ‘the crucible in which the future shape of the progressive centre-left
politics is being forged’ (Reid, 2005a; p.2) – support for Patient Choice was
neither unconditional nor universal (Bate and Robert, 2005). A report by the
National Audit Office found that the roll-out of ‘e-booking’, which allows
immediate electronic booking of patients' choices, was slow: only 63 bookings
had been made by the end of 2004 out of a workload that will eventually
involve millions of bookings.
Other systemic problems have also been put forward as reasons for the
‘stickiness’, whereby patient choice remains more concept than reality, and
patients are not moving around the system as freely and easily as advocates
of the market would want or have expected. For example, according to a
recent national study, top-down implementation and poor strategic planning
would appear to have led to many TCs being built in the wrong places:
New capacity (or measures to use existing capacity better) needs to be focused
on the areas surrounding London, on East Anglia, and on Devon and Cornwall.
These are not the areas in which diagnostic and treatment centres are to be
located, thus given the current patterns for referral and capacity these facilities
may do little to increase choice.
(Damiani et al, 2005)
As one of our interviewees put it:
There’s no point in putting a fantastic supermarket on the Isle of Skye and set it
up to service a million people if you can’t get the customers to it.. You’ve got to
get the customers to the people who are delivering provision.
(Senior manager)
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Then there are problems or shortcomings within the systems themselves, for
example a number of our respondents described how they had failed to
anticipate the practical difficulties they would encounter in moving patients
between providers, because adequate information, financial and clinical
systems did not exist, or had never been designed with this in mind. Poor
financial and administrative mechanisms for facilitating the movement of
patients around the system contribute further to the ‘stickiness’ mentioned
above; administrative blockages or planning inadequacies prevent or slow
down the ‘transfer’ of patients between providers.
5.4 Payment by Results
To enable patient choice to apply nationally, the Department of Health
introduced a new system known as Payment by Results, which aimed to
directly link a hospital’s income to the amount of work it performed (Harrison
and Appleby, 2005). This new system was partially introduced in April 2003.
Tariffs (based on health care resource groups) were initially applied to non-
emergency surgery for 15 procedures, including cataracts and hips, both
areas where there were significant waiting lists, and both prominent in TCs.
Foundation trust hospitals also started to use the system for nearly all their
activity. In the autumn of 2003 the Department of Health published a
consultation document which identified four principal policy directions that
Payment by Results sought to underpin: devolution, choice, plurality and
investment.
Although originally scheduled for all elective, emergency and outpatient
activity from April 2005, the Department of Health’s implementation plan for
Payment by Results was changed significantly following a review of its scope
announced on 10 January 2005 in a letter from the NHS director of finance
and investment (Department of Health, 2005d). This change meant that the
tariff would now only apply to elective activity in 2005/2006 and that non-
elective activity and outpatients would be brought on line in 2006/2007. This
change was a response to the financial rebasing exercise, which all trusts had
been asked to complete before the end of 2004. The ‘last-minute’ move was
seen as an emergency measure to halt a process that could have triggered a
crisis in PCT finances. This was largely because the Department of Health had
based the tariff on activity levels for emergency care in 2003/2004, which
had since increased. Then, more significantly, in early 2006 the Department
of Health had to withdraw the full 2006/07 national tariff only weeks after
publication. The tariff was removed pending work to correct errors in the
original calculations. Some of our case study sites were taken unawares by
the Payment by Results initiative, which undermined their original financial
assumptions and the ongoing uncertainty about the tariff made financial
forecasting problematic.
5.5 NHS Elect
One of the responses to the challenges facing TCs as organisational
innovations was the establishment of NHS Elect. Formed in 2003, NHS Elect
started out as an umbrella organisation representing a small number of TCs,
but now includes other elective care providers besides those that run TCs (see
www.nhselect.org.uk). NHS Elect offered its members:
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• networked specialist knowledge and expertise (including arranging visits
to the US to view the surgicenter model)
• patient information and marketing literature, ‘all with a common ‘brand’
and image’
• active marketing of spare TC capacity across the UK
• links with the Department of Health and other national teams.
To commissioning and referring agencies (‘partners’) NHS Elect offers a one-
stop resource for information about the group of TCs it represents, including a
price list for procedures offered by each site compared with the NHS’s
national elective spell-based tariff (NHS Elect, 2004; Timmins, 2003).
Please note that data in the remainder of Section 5.5 is based on a series of
interviews with senior managers in NHS Elect, unless otherwise stated.
5.5.1 Origins and early history
NHS Elect (which at least one early proponent wanted to call ‘NHS Elite’)
developed from a Department of Health sponsored project called ‘First
Movers’, which was established to challenge traditional ways of working
within elective care by bringing teams of doctors to the NHS from overseas.
In 2002/03, one of the ‘First Movers’ initiatives employed overseas and UK-
based surgeons to offer patients in London the choice of having their routine
general surgical and ear nose and throat operations performed more quickly
at the Central Middlesex Hospital’s Ambulatory Care and Diagnostic Centre.
After the end of the project it was felt that it might be useful to have a more
permanent collaboration between a group of NHS trusts who were keen to
prove that separating elective from emergency care was a good idea.
The underlying intention was that NHS Elect would – in some way – form a
chain (‘a franchise arrangement’) in which members would work together and
compete effectively with the independent sector TC chains which were at that
time being established. The model originally adopted was that the TC
members would fund NHS Elect themselves:
It would be worth their while to do that at a reasonably high level because of
NHS Elect bringing in additional activity and showing how to deliver a different
model that would then deliver cost efficiencies as well as a better patient
experience.
(Senior manager, NHS Elect)
NHS Elect had a board that comprised the chief executives of the founding
trusts and the initial plan was that managers employed by NHS Elect would
go and work within TCs, but this was thwarted by governance problems (who
were such managers accountable to: the trust or NHS Elect?). NHS Elect was
established successfully and rapidly, but was less successful at ‘actually
delivering stuff on the ground’ according to both its own managers and our
case study site interviewees during this period. We were unable to find any
public centralised information as to the scale of activity undertaken by NHS
Elect to date, nor about any value added to TCs’ activity by the consortium
arrangement. However, ‘Google’ searching using the phrase ‘NHS Elect’
identified several reports from individual providers or commissioners. For
example, increasing numbers (envisaged as up to 1500) of surgical NHS Elect
patients from Wales were reported as being treated at the Worcester TC
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(West Midlands South Strategic Health Authority 2004). Also, the Royal
United Hospitals NHS Trust in Bath, a no-star trust with a troubled recent
history, made a substantial volume of information available on the web. This
revealed that its local PCTs planned to transfer 1000 orthopaedic cases
(presumably in 2003/4 financial year) from Bath to NHS Elect in their efforts
to achieve waiting list targets and implement patient choice.
5.5.2 Re-launch and expansion
After a slow start in its first year of operation, NHS Elect was relaunched with
a reaffirmation of commitment from the chief executives serving on the board
as well as the establishment of a new medical advisory board. NHS Elect was
now expected to provide its members with the following in return for £40,000
from each member organisation:
• It would implement a model of care (‘a draft blueprint for elective care
within TCs which included around 40 recommendations or stipulations’)
derived originally from a visit to one TC by representatives from a US
surgicenter who made a series of best-practice recommendations.
Following on from this, NHS Elect began working on models of care for 15
procedures with the main aim of standardising patient experience across
its member TCs.
• It would establish best-practice links (that is, sharing knowledge)
between the TCs in NHS Elect and provide foreign teams of doctors.
• It would market the spare capacity available in the member TCs.
Interestingly, this included exploring the possibility of selling back spare
NHS capacity to independent sector TCs
• It would brand all of the NHS Elect TCs with a ‘common look’ for example
for patient literature.
Building on its existing member TCs, in 2004 NHS Elect expanded with
explicit Department of Health support to include some 10 TCs. NHS Elect was
mandated to help implement ‘the practical day-to-day stuff’ because, as one
of the NHS Elect managers pointed out:
They’ve got just so much on their plates… that they haven’t got time to wade
through a 99-page ‘step guide’… When you’re running a busy organisation you
just don’t have time to do that.
By the end of 2005, NHS Elect had grown to cover 17 TCs and had become
part of the formal infrastructure of support provided by the Department of
Health Short-Stay Elective Care Programme to the NHS, with the stated aims
being to provide ‘a very practical bundle of support’ which included
• a common experience for patients
• core marketing and consultancy support to members
• opportunities to innovate and spread good practice quickly
• consultancy/accreditation for others
• new opportunities for collaboration with the independent sector.
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5.6 Summary
The policy environment we have described evolving over nine years was
highly complex. For NHS-run TCs, their experience has been an uncertain
political climate and apparent conflict between the national and local level,
and this has provided a distinctly (and as far as those at the trust level are
concerned, unforgivably) ‘unreceptive context’ (Greenhalgh et al, 2005) for
innovation, modernisation and change. We see the independent sector TC
programme, Patient Choice and Payment by Results as key influences on the
development of TCs in the NHS, but perhaps the most significant of these has
been the increasing involvement of the independent sector in health care
delivery and the presence of independent sector TCs. The questions facing
NHS-run TCs, confronted by this policy, were:
1 Are independent sector TCs simply here as a driver for change, to shake
up the NHS and drive out inefficiencies, or is there something more
fundamental about to occur, namely the long-term restructuring of
health care provision in England?
2 Are independent sector TCs here to fill short term gaps in NHS capacity,
or is the NHS now competing with the independent sector? (Carvel
2005).
The answer, from the Department of Health, to the latter question seemed
clear:
Choice of elective treatment will both improve the patient experience and
encourage providers to develop more responsive, patient-centred services.
Putting patients in charge of where they are treated means that all providers, IS
or NHS, have to compete for patients and this competition helps drive a patient-
centred service… Once a competitive challenge is introduced it forces the
existing provider to re-examine their processes to perform as well, or better than
the new provider.
(Department of Health, 2006b)
However, the philosophy of expanding independent sector involvement (to
increase choice) has led to incentives and regulation to encourage
independent sector TCs to enter the health care market that have not ensured
a level playing field for NHS services. While independent sector TCs have
guaranteed five-year contracts at above the market rate (to encourage their
involvement in the NHS), spare local NHS capacity has to be funded in the
face of uncertainty about even short-term activity levels. Coupled with the
policy of Patient Choice, such incentives of the private sector have proved a
major threat to the viability of TCs in the NHS, as one of our respondents
pointed out:
It’s all very well saying you have flexibility and choice but that’s the problem;
you’re left with an asset that has a huge overhead that you just can’t meet. And
that’s the taxpayer footing the bill at the end of the day. You need to try and
generate a situation where people do have choice but where you don’t have a
facility like [our TC] that’s half empty. There must be a middle way. You could
probably operate at five per cent under capacity but not at 50 per cent
(Senior manager)
Failure to respond to these uncertainties, as the following sections will show,
led to financial deficits and uncertainty for TCs in the NHS and to the
perception that independent sector TCs have an unfair advantage.
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NHS Elect was formed, in part, as an attempt to mitigate the negative effects
of the policy environment in which NHS-run TCs had to operate. One of its
aims was to create a sense of identity for its members – but even this was
more difficult in the NHS than in the private sector as one of the NHS Elect
managers remarked:
One of the advantages that the [independent sector] has is that they can create
a corporate ethos so that everyone who works in their TC understands what the
organisation is about. Within NHS Elect that’s more difficult because they’re not
only part of a TC – although … some of them don’t even realise they are – but
they are also part of [a] trust, they’re also part of the NHS; they’re part of [a]
Hospital. There are all sorts of different affiliations and incentives and drivers.
As a programme of organisational innovation, NHS-run TCs are a good
example of how an unreceptive environment, characterised by high
unpredictability and uncertainty, can significantly undermine a policy
initiative. This environment also includes the historical legacy of perverse
incentives that continues to exert influence in the NHS, and the fact that the
current commissioning process is not sophisticated enough to keep pace with
the speed of reform demanded by the implementation of Patient Choice. The
problem facing many TCs was how to survive in such an environment:
There is an increasing realisation on the part of the policymakers that these
[TCs] were a vehicle for great innovation and change, and now the people who
are left holding the baby are basically in a terrible position that is not largely of
their making. These business cases were signed off. They were predicated on
doing additional work in order to meet planned targets, and the fact is that that
additional work is either going to the independent sector or that the money
somehow isn’t with the commissioners. The commissioning process is too
fragmented to be able to support system-wide SHA facilities. And the response
– which is the automatic response of NHS trusts during financial difficulty – is
shut down, take out capacity. Let’s reduce anything we don’t have to do. Let’s
shrink …most of the places are not the exciting, innovative, energised places
that they were. They are people who are struggling to keep their heads above
water.
Just how successful our sites were in ‘keeping their heads above water’ as
events unfolded is discussed in Section 6.
For further discussion of many of the issues raised in this section, see also
Bate and Robert (2006).
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Section 6 Achieving the goals? How the treatment centres evolved
Our aim in this and the following section is to examine how and why the TC
programme evolved in our sample sites in such different ways. It will be
evident from the preceding sections that the exigencies of local circumstances
(the internal and external milieus described in Section 3) and the wider policy
context with its plethora of national initiatives (Section 5) ensured that our
case study TCs had anything but a stable or predictable environment in which
to fulfil their espoused (and actual) objectives, particularly with regard to
their task of introducing innovative models of care. There was major
turbulence as the ground shifted both under the original TC programme and
under most of the TCs’ own local aspirations. It will become clear that most of
the TCs were obliged to depart not only from the central model of TCs as put
forward in the Government ‘frame’ (see Pope and Robert et al 2006), but also
from their own original local intentions (Section 4). We show that this was not
just a matter of TCs and their host trusts reacting contingently to changes in
their environment (what Burgelman (2002) calls ‘autonomous strategic
action’). The local and national TC initiatives could also actually help create
the often adverse and destabilising environmental changes to which TCs
found themselves having to respond. In this way TCs were to some extent
actually, as Weick (2001) describes, ‘enacting’ their adverse environments.
We do not offer this as a criticism but as support for the emerging view of
innovation as a ‘complex responsive process’ (Fonseca, 2002; p.4), evolving,
unpredictable and improvisatory, rather than rational, regulated, controlled
processes (see Section 10 for further discussion of this view). In a similar
vein the emergent process of our sample TCs reveals one of the great
paradoxes of innovation: that the activity of innovating, which aims to create
security and stability is, ironically, that which produces insecurity and
instability (Fonseca, ibid).
In this section we discuss how and why the initial plans rarely worked out as
intended, and the role played by the pressurised nature of the initial
planning, the subsequent impact of shifts in national policy, the state of
relationships with partner organisations, and role of internal developments
and staff changes.
6.1 Planning
6.1.1 Incorrect planning assumptions
As time went on, most of our sites struggled with an inability to predict
accurately what their activity or casemix would be. The TC at Site A was a
poignant example that became a severe financial liability for its host trust; it
faced a deficit of over £10m in 2004/05 and then annual debts of around £5m
per annum over the next five years. As we saw in Section 4, the intention had
been to bring in large numbers of routine patients from a wide geographical
area through the new Patient Choice scheme; and at first it did indeed receive
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the lion’s share of patients allocated by that scheme. However, the TC found
itself dealing with fewer routine cases than its had intended:
We thought we could push volume through. Then we started to have a look at
what was actually on the list and it was really quite interesting. The lists are,
by their very nature, full of patients who are old… co-morbidities, complex
patients, social problems… there is quite a bit of complex work in there. So, very
quickly we thought, ‘mmh, this isn’t what we thought it was going to be’, once
we started to break through the waiting list.
(Site A: senior manager, host trust)
A lot of [Site A’s] early problems were they weren’t geared up to deal with
common co-morbidities
(Site A: SHA manager)
It became increasingly clear that once the backlog of waiting list patients had
been cleared not enough patients were being referred to the TC. Within a year
– by which time the number of TC beds had been increased fourfold – the
flow of patients was only half what had been anticipated, and the TC was not
financially viable. The managers began looking for efficiencies, including a
shift from inpatients to day cases, and ways of streamlining services and so
on, ‘altering the way we do things, looking at everything again’. Innovation at
this stage of the TC’s development was being driven not by an idealist drive
towards modernisation, but by opportunism and the sheer pragmatic need to
find new markets and greater efficiencies in order simply to survive. However
this inevitably meant that the casemix began to change. In short, the
planning assumptions about the type of casemix that the TC would attract
turned out to have been completely wrong. So was the idea, it rapidly
transpired, that the TC would treat the majority of patients from the
neighbouring areas. Indeed nearly everything soon conspired to undermine
the original plans, which were retrospectively described by one local senior
manager as having been quite simply ‘a crap business case’. The phrase is an
interesting one, since given the unpredictable nature of the innovation and
the environment one wonders whether a superlative business case
(systematic, measured) would have been any more accurate.
Site F was another of the TCs that suffered from planning assumptions about
activity levels that could not be realised once the TC opened: by the end of
the first year of opening the shortfall was approaching 50 per cent. Most of
our informants were clear that here, too, the problem was rooted in a failure
to think through such questions as the likely referral rates of patients and
hence sources of income:
Well actually financially it’s a mess because the business case never stacked
up in the first place, because nobody really understood where the activity was
to come from. Assumptions were made that it was all going to come from Patient
Choice, or directly from originating trusts, or directly from GPs, but nobody
actually went out there and did a proper market analysis to find out if that is
actually what’s going to happen… There was no continuance of money, no
scenario funding or options funding, nothing like that, which to my mind is not
good business. And surprise, surprise, it hasn’t worked… You know when they
did the capacity modelling here, they looked at three thousand cases – ‘we
need x number of beds and x number of theatres – but what they didn’t do was
look at outpatient activity. So even for two and a half thousand cases I don’t
have enough outpatient capacity, so I have a bottleneck at outpatients. Ooh, it
makes you angry (laughing).
(Site F: senior manager)
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It’s opportunistic money, like a lot of these things are. It just doesn’t strike me
that it was run along good business lines. I wouldn’t start without knowing how
much money you’ve got. No, certainly that’s a real issue. We now are told that
we’re in the red but then again we were never told how much money we had or
didn’t have or were allowed to spend… The real background to it is we were
given very little information, very little knowledge to budget and just rough
figures for, okay, well, you need to do two thousand cases without telling us the
case mix but, have a guess and see what you can get.
(Site F: senior clinical manager)
One of the central problems for TCs was that in order to plan they needed to
predict accurately the likely caseload, but most had to make fairly broad
assumptions on very unsound data. We heard little evidence of there having
been much informed debate at the time that the business cases were being
considered by the higher echelons of the NHS. Typical comments – which the
speaker often illustrated at some point by waving a wetted index finger in the
air – were:
One of the issues with all this is that nobody could ever actually tell us, when
we went to all those strategic meetings and all that sort of thing, what the size
of the waiting list out there is and that whole figure that everyone pins their
maths on is not clear and if it is calculated, it’s not accurate. When you actually
see the patients, a fair proportion are down for the wrong operation or don’t
want the operation at all. So, it’s really stark and very shaky data.
(Site F: senior clinical manager)
[The planning by the host trust] wasn’t very sophisticated but then the time
frame was such that there wasn’t sufficient time in the process to do that in
terms of working it out and there were a couple of mistakes made. The main
mistake that was made was an assessment made of the lists which was
inaccurate in that 70 per cent of the cases would be minor… 30 per cent would
be [major]. In fact it turned out nearly to be the reverse.
(Site A: senior hospital manager)
At Site B – the only one of our TCs that had not suffered from over-optimistic
initial estimates of activity, but where the TC was an integral ward within the
hospital – plans are still in progress for a stand-alone second phase TC, which
will be more similar in its function to the others in our sample. Discussions
about the planning process for this phase revealed not only that the original
estimates of its capacity had been severely questioned by a formal review
from the Department of Health, but that there seemed to be little good
evidence to support either the larger or the smaller predictions. Despite
repeatedly revisiting their assumptions in the light of the review, the TC
design team saw no reason to reduce the capacity significantly. The senior
managers on the project team told us during a group interview that they
simply had to proceed on some basis, even though they knew there was huge
uncertainty. Not to start building was not an option from the trust’s point of
view as they were relying on the new TC as a key part of the future strategy
for the survival of the trust as whole. The following quotations illustrate not
only the uncertainty that was so widely found around quantitative
assessments of the need for given services, but also the fact that external
events were constantly undermining or eroding those assumptions. In this
case the region was in the midst of struggling to reconfigure services across a
number of trusts, the government had just introduced Payment by Results
(Section 5) which looked likely to have a major but as yet unquantifiable
impact on the financial basis of the new build; and the public- private
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partnership requirement to provide up to 15 per cent of patients with care
based in the independent sector was also looming as a possible challenge for
the TC. What is interesting in the following quotations is that some of the
practitioners, like the academics above, are themselves to be found
questioning and doubting the ‘planning approach’ to innovation:
You have to be pragmatic. I think that’s an interesting point, around planning,
as well, when you talk about what planning assumptions we made, what
activity, capacity assumptions we made in this. You can plan to a certain extent
but you only need to look at the strategic health authority around the planning
for orthopaedics. Plans very rarely come to fruition, I find – activity plans in the
NHS. And so you’ve just got to plan it the best you can and then move forward
and, like [senior manager 2] said, it’s never going to be perfect.
(Site B: senior manager 1)
If we took this capacity planning round and said, right, that’s the baseline, you
can guarantee that in two years’ time it will be something completely different
or, like we said before, you can wait another two years and do nothing and
then in two years that will be different again.
(Site B: senior manager 2)
Site D ran into problems, some of which might perhaps have been predicted
with a more careful analysis of the need for health services in that region, but
others of which arguably could never have been anticipated because of the
time-lapse that always occurs between the conception and implementation of
an innovation. The TC ran at around 65 per cent capacity until it eventually
met its original monthly throughput target some 20 months after opening.
The rationale for the original model had been arrived at several years before
the TC programme was launched, and had not been adequately revisited or
tested in the rush to obtain the funding to open the unit as part of that
programme. In the event, waiting lists fell dramatically as other TCs opened
nearby both in the NHS and the independent sector, which again meant that
there was less work to be done than had been envisaged. Moreover, Site D’s
TC proved to be more expensive than its competitors: the average price for
one standard operation within that specialty was £4500, but at Site D was
£5500. This was partly due to predictably high capital charges, rates and
service costs, but there was also an unanticipated (though possibly
predictable) shortage of qualified staff requiring the use of expensive agency
staff to fill vacant posts. (Mistaken assumptions about the costs and savings
from changes in staffing levels also undermined the intended switch to a
nurse-led service – see Section 7). The unanticipated extra costs of the TC
were also partly attributable to the high overheads accruing from its
associated high dependency care unit that was greatly underused since – in
contrast to Site A, which found itself dealing with unexpectedly complex
patients – the casemix at Site D had been much more straightforward and
routine than had been planned for. There was therefore little call for the extra
facilities that had been committed to dealing with more difficult cases.
Moreover the plans for the routine patients were formulated on lengths of
stay that had been based on US experience and could not – or would not – be
adhered to by the senior medical staff, which also added to the costs. There
were also some early teething problems with essential off-site support
services that required outsourcing, which added to the financial loss totalling
more than £4m in the first year. This devastating cocktail of problems was
compounded by a completely unexpected policy initiative six months after the
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TC officially opened when the government introduced practice-based
commissioning coupled with the introduction of the G-Supp scheme (see
Section 5.2.1). This made it cheaper for the local PCT commissioners to send
the patients to the independent sector or to other trusts, which – inevitably –
they did.
Site C's original plans suffered from a different kind of unexpected setback.
This TC's business case relied on activity from neighbouring PCTs that had not
previously sent patients to Site C, but were now determined to do so because
of poor performance in their traditional provider hospital. Shortly before the
TC was due to open, these PCTs revised their commissioning plans – not
because of any dissatisfaction with Site C, but because their previous provider
had now shown itself capable of handling the work satisfactorily. This
dramatically reduced the projected activity for Site C and was a huge blow as
no contingency had been made for such an eventuality in the TC's plans. And
yet, as one manager who had inherited that situation put it, it might have
been wiser not to expect the assumptions to be accurate:
The plan assumptions we were using were never as robust as they thought they
were, but I’ve been very clear all along – the experience from other treatment
centres is it don’t matter how good your commissioners or how clear their
intentions are… what actually walks through the door in terms of patients at the
end of the day is totally different.
(Site C: senior manager)
Site H also appears to have had some very inaccurate capacity planning
assumptions underpinning its original business plan for the TC. Planned
activity level had been put by the finance and information departments at
around 3500 FCEs per annum, based on (a) existing workloads, (b) rate of
referrals, (c) likely growth and (d) national assumptions. But the team who
had been employed to run the TC some time after these figures had been
posited, saw the figures as ‘unrealistic or just plain wrong’ Their view was
that the capacity estimates for the TC might be over-inflated by as much as
300 per cent. They were also concerned to rectify the omission in the original
plans of a dedicated operating theatre, which they regarded as a missed
opportunity that was – in the event – turning out to be essential for the
success of the TC. (One manager told us that if this theatre failed to open by
the end of 2006, ‘we’re stuffed’.) Reflecting on how the plans for the TC at
Site H had come about, an experienced SHA manager suggested a
comparison with other NHS initiatives they had been involved with, such as
NHS walk-in centres:
You have somebody that comes up with an idea. That idea then gets fleshed
out and has to be knitted back towards NHS policy mainstream. And it then
gets knitted into our wider scarf than the little tiny bit of scarf that was
originally being knitted. So it was like all of that with NHS. You then developed
a branding, almost, and you developed a brand for both walk-in centres and
treatment centres. The problem is that the brand that you end up with doesn’t
necessarily fit the bid that was originally around the initial stages of the
process.
(Site H: SHA senior manager)
Nevertheless, despite the overestimate of likely activity, which meant that the
TC was soon running at between a quarter and a third of the expected
throughput –soon after opening it was already completely empty on some
days – it was able to adapt and increase the numbers steadily, though still
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well short of the original expectations. Meanwhile a financial shortfall in the
host trust meant that in any case the whole project had to be scaled down.
Site E also found that they had been over-optimistic in their expected
throughput, thanks also to poor planning assumptions. Initially they planned
to receive patients from a geographical area beyond the boundaries of the
host trust but in reality, by their second year of opening, the distant locations
had either not signed up to sending patients or had found closer, cheaper,
more appropriate alternatives. As one PCT representative told us:
But the main problem we’re having is the relatively restrictive list of procedures
and the prices they charge making them not particularly attractive and certainly
no more attractive than some of the [local] private sector. Also, the private
sector, even if they’re slightly more expensive [may] do a volume deal.
(Site E: PCT manager)
As in Site H, the team was able to adapt to the problem, in this case by
successfully marketing with other distant commissioners through engagement
with national networks. Likewise Site G was another that soon found itself
with spare capacity and underutilised facilities and staff. This site had initially
wanted a day case unit that would serve its local population, but had
opportunistically expanded the scale of its plans to secure TC funding. As in
Site A, the case for this rested on an assumption that the TC would attract
patients from a much larger geographical area. However, demand ‘dried up’,
partly as the sending trusts engaged in their own ‘waiting list busting’ but
also because patients proved less willing to travel than anticipated and,
perhaps more importantly, these distant trusts were extremely resistant to
the idea of sending their patients to an unknown facility. (Waiting lists are
often seen as being ‘owned’ by the consultant who makes the decision to
operate. These decision-makers were often unhappy with their patients going
elsewhere. In the most extreme example of this a consultant based at a trust
engaged to send patients to Site G wrote to his patients expressing concern.)
In short, seven of our eight sites found themselves in difficulties because their
initial assumptions about the likely numbers and/or casemix of patients
turned out for one reason or another to have been over-optimistic or
erroneous. The eighth was a very different kind of unit, integral with the host
trust and acting as a capacitor to increase patient turnover across the whole
surgical division, and excess capacity was therefore never part of the picture.
Even at that site, however, the planning for the phase two stand-alone TC has
involved some major disagreements based on uncertainty about its eventual
optimal size that remained unresolved.
In the turbulent and often unpredictable world of the NHS, planning seemed
casual, and apparently little care was taken to test the assumptions of the
business cases or draw up contingency plans. It is striking how often and how
badly so many of our case study sites got it wrong, and how much of the
subsequent effort was spent in trying to rectify the consequent difficulties,
difficulties that mean that about half of our sample, as things currently
appear, the innovations will not be able to survive in their present form, if
they survive at all.
Why did the eventual course of the TCs’ workload differ so dramatically from
that which had been assumed at the planning stage? The poor information
and lack of predictive capability discussed above clearly had a huge impact
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but our findings also suggest a number of other reasons which we discuss in
turn below:
• pressure (both from external demands and internal enthusiasm) to move
fast at the bidding stage, and a tendency to ‘cut corners’
• changing circumstances, not all of which were unpredictable, and the
lack of adequate contingency plans
• lack of support from external partners (including PCTs, SHA, trusts) who
were not sufficiently engaged with the project or had conflicting
priorities, and, linked to this, a lack of strategic planning across partners
• inability to realise the ambition to draw in patients from distant sites (an
aspect of ‘market failure’ as described by Bate and Robert, 2006)
• inadequate support from internal stakeholders (including clinicians and
managers in the TC but also internal systems and contractors)
• sometimes ambivalent relationships with the host trust.
6.1.2 Pressurised planning
As we saw in Section 4, the pressures from all levels of the service made it
imperative to increase elective capacity across England within a short
timescale. At most TCs, the host trust needed to capitalise on the opportunity
to acquire additional capital funding, which also had to be competed for
within a short timescale. The PCTs, SHA and trusts felt that they needed to
act quickly so as to hit government targets. In some places senior leaders
wanted to be seen to be at the forefront of this innovation, and therefore
sought to secure a number of TCs. The Department of Health and the
government wanted to implement the TC programme so that they could
demonstrate that the NHS was modernising at a rapid pace. And within the
TCs and their trusts, the local idealists were anxious to get on and introduce
as soon as practicable their innovative ideas to improve care. These and other
pressures conspired inevitably to produce a rushed job that ignored (or more
accurately perhaps, chose to ignore) the shakiness of many of the basic
assumptions. And all of this was unfolding rapidly in a context of impossibly
tight deadlines.
Things happened so quickly in that we were waiting for a long time to find out
how much money we were going to get, then all of a sudden a decision was
made, and ‘it’s OK, here you go, now open the [diagnosis and treatment centre]
and make it work by Monday.
(Site F: senior manager)
It all started ‘on the back of an envelope’. [A senior clinical manager] was
accosted by the operational director in the street, who said ‘It’s all very exciting
because we’ve been made a first wave [diagnosis and treatment centre].’ ‘Great,
but what’s that?’
(Site F: senior manager)
The conversation I had with [the Department of Health] was quite bizarre. He
said, ‘I hear you can open a day case unit treatment centre quickly?’ I said, ‘Oh
yes, we’ve got the shell, we could do it.’ ‘How quickly could you do it?’ ‘How
quickly would you like it?’ ‘Well, the Prime Minister wants it tomorrow to sort
out the [local trust problem]. He wants all these two-year waits sorted in 18
months.’ ‘In five and a half months we’d probably do it if you give us the
money, [X] million pounds, that’s what we need and you have the treatment
centre, I can open and we’ll bring the overseas teams in and we can do it.
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(Site G: senior manager)
[The planning and modelling] was done by [X]; it wasn’t very sophisticated but
then the timeframe was such that there wasn’t sufficient time in the process to
do that in terms of working it out and there were a couple of mistakes made.
(Site A: senior manager)
One site which did not appear to have quite such a pressurised planning
process was Site D. Some of the planning behind this TC had been under way
since the mid 1990s, (albeit in a slightly different form). Like the other sites
there was some opportunism in linking these plans to the TC programme, but
it is striking that simply having this additional planning time did not prevent
them encountering the very same problem of uncertain workloads and failing
to adequately adapt to the changing wider context. Knowing as we do the
problems that came later because of pressurised ‘back of an envelope’
planning in several of the sites it would be easy to say that more ‘slack’ in the
system, especially in the early stages, would have made a difference.
However, given that it seemed everyone would gain from having a TC, it
would probably have taken a very brave person at the time to intervene and
slow things down in order to allow more time for planning and reflection. The
presence of Site D as a disconfirming case here also suggests that it may be
the quality of the planning, not the time in which you have to do it, that
matters. The issue that may be of greater interest and relevance to theorists,
policymakers and practitioners is how to avoid ‘groupthink’ (Janis, 1972) and
the collusion that accompanies an innovation that appears to be all benefits
and no downsides (the colloquial ‘no-brainer’ - a term often heard in
discussions about TCs or at least the philosophy underpinning TCs).
6.2 The shifting ground
We saw in Section 5 how a plethora of initiatives from central Government
affected the TC programme. This was not just a matter of competing priorities
for managers. Nor was it the tendency for some managers to (as was often
said) take their eye off the ball because a new initiative now loomed larger in
their field of vision. Such tensions are taken as read in senior management,
and were fully to be expected in this instance. However there was a clear
impression among many of our informants that the NHS had been going
through a particularly intense period of change and reorganisation since the
NHS Plan, which itself had followed a long series of reorganisations under the
previous administration. There was therefore a strong feeling of ‘battle
weariness’ or change fatigue among many managers and clinicians. There
was often also a lack of continuity and corporate memory that may have
contributed to the failures in adequate planning and networking that might
otherwise have helped to avoid the mistakes that occurred. But one thing was
particularly specific about this particular innovation: many of the
government’s parallel initiatives actually worked to undermine its success.
The following three policies were seen as presenting a special threat to the
evolving NHS-run TCs (see Section 5 for the background to each of these).
6.2.1 The rise of independent sector treatment centres
The Government push to involve the independent sector more in the delivery
of care for NHS patients and the independent sector TC programme in
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particular had huge implications for some TCs in the NHS. An internal report
for one of our sites suggested that:
The net effect of the private sector, independent and NHS treatment centres
combined with the activity currently taking place in host trusts will result in a
massive over capacity in the market. This is the biggest threat to [the trust’s]
survival.
(Site A: internal report 2004)
A view that was reiterated by one of our respondents at this site:
They insist on pursuing this independent sector nonsense, and I think that’s
what we find so frustrating. I think from the government’s point of view, they
just say, we’ve just got to increase the capacity, we’ve made this commitment to
an independent sector, 15 per cent or 20 per cent, or whatever, and everyone’s
work has got to go through the independent sector, and that’s the promise we’ve
made. Well, that’s fine, but then you are going to lose some NHS treatment
centres as a result, so they’ve got to decide somehow, how that’s going to work,
because you’re not going to be able to have it every way.
(Site A: clinical manager)
The impact of the threat from the independent sector should not be
underestimated. Indeed in the later phase of our fieldwork at least three of
our sites (A, D and H) were considering selling capacity to the independent
sector or entering into some form of partnership with them:
We believe that one of the longer term solutions is to work with a private sector
partner in partnership or to hand it over to them and we’d provide the clinical
services. Or not even that necessarily ... Or even to give them a part of the
facility to run independently. All options are open and have been explored and
I’m sure will continue to be explored… We’ve had [names various independent
sector companies, international and national]; they’ve all been round. At the
moment it’s a failing business.
(Site A: senior manager)
In 2005 Site D entered into discussions about leasing the TC to the
independent sector; a plan that the trust explicitly linked to the government
policy of promoting private sector provision and increasing plurality. One of
the local PCT commissioners concurred:
Hence perhaps the model of the NHS treatment centre may not be the most
appropriate. A public company could do it for if not less money, better value for
money, I think because in the NHS it tends to be rather difficult to change
structures, and to change direction because of the nature of the beast. It’s a big,
complex organisation and it takes a hell of a lot of time to turn it round or to go
in a slightly different direction. Smaller organisations tend to be fleet of foot;
hence things can happen very much quicker. I mean I have every confidence
that eventually we will have a multitude of treatment centres; I think the model
is wonderful. And we’ll be able to get services for our population from any of
those centres. The advantage of doing it outside the NHS is it breaks the
monopoly of the consultants, the stranglehold of the consultants, which I don’t
think is an appropriate model. It doesn’t do anything for patient care, but
similarly we’re moving towards having a multitude of different types of
provision in primary care as well to break the power of the general
practitioners. I think that’s fine as well.
(Site D: PCT senior manager)
While this transfer of an NHS-run TC to the independent sector appeared to
have the support of the Department of Health, it met considerable opposition
from other quarters. Pressure groups leaked information to the press and
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local campaigners challenged the trust to explain the reasons behind the
plans with the result that the plans were postponed. At this site, as at Site C,
there was also considerable trade union opposition to the increasing
involvement of the independent sector, which was viewed as ‘privatisation by
stealth’ and in both sites this led to national level union campaigning on this
issue.
6.2.2 Patient Choice
At least four of the sites (A, D, F and G) anticipated numbers of ‘Choice’
patients which simply did not materialise in the early days of the unit. Part of
this as we have already noted (Section 5) was because patients were
reluctant to exercise such choices, as one of the PCT senior mangers
explained:
I think that when targets are set people don’t really appreciate how difficult it is
even to actually be ringing up patients and offering them choice, and the
patients are wondering why they’re being offered the choice and don’t quite
understand. We’ve had that experience within NHS. The patients say why is
this person phoning me, who are, why do they want to move me. No, I don’t,
thank you very much.
(Site F: PCT senior manger)
Perhaps ironically the Patient Choice initiative was undermined by the
apparent success of other waiting-list-reducing policies:
I think this year we probably only sent about, and [had] accepted, I think about
190 cases from Patient Choice and it really has fallen off big-time, I mean we
were doing several hundreds last year. So it’s a big drop-off but it’s obvious
that, as the waiting list gets under what an individual perceives to be not
unreasonable, I think probably in the six month area, I don’t think three to six
months is a big deal to an individual, but nevertheless you get less take-up,
and people are unwilling to travel and they’re unwilling, certainly once they’re
in the system, to change consultant.
(Site F: senior manager, neighbouring trust)
Some of our TCs also reported that prevarication by ‘sending’ trusts reduced
the numbers of such patients:
We’re reliant on them giving us the names from [geographically more distant
trust] and they’ve been very slow at sorting out the waiting lists and actually
identifying the patients. So until we actually get the patients to ring up and start
booking, there’s nothing we can and [they] have been very slow to get those
lists of patients across to us.
(Site G: senior manager)
That said, not all the case study TCs were expecting the Patient Choice
initiative to have any impact on them:
I think also the impact of the [Patient] Choice initiative will be very minimal in
the early stages because we’re not planning to have any six month plus waiters
by the trigger dates for the initial phase and choice. The other issue around
December 2005 and patients being offered a choice, the risk of losing patients
when offered choice we believe to be fairly small… [Describes a previous move
of surgery site X to site Y]… There’s no evidence that people are switching
away. The second I suppose is the type of population that we have. The
majority of the population is not the most mobile. There’s a feeling that we’re
not going to lose it, and I suppose there is a third. We’re going to be offering
brand spanking new facilities. Brand new facilities are more likely to attract
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than deter patients. So, given those sorts of things, who knows what will
happen, but we’re not expecting to have a significant loss of patients.
(Site H: senior manager)
6.2.3 Payment by Results
Payment by Results represented both an opportunity and a threat to the TCs.
The perceived complexity of the proposed tariff coupled with a lack of
understanding as to how the new financial system would work meant that
some felt that the system would ‘be a shock to some… the message had not got
through yet even though the TC is where big gains could be made’
(Site H: senior manager)
Thus at Site G there was recognition that the TC could potentially benefit
from the new tariff payment system as their costs were some 10 per cent
under the initial Payment by Results tariff charges (largely due to the
historically small size of the trust and lower than average staffing costs). Yet
for others there was concern that Payment by Results would prove to be
another challenge to the viability of TCs:
Payment by Results has not gone live in the way that we expected it to. [Trust
X] is still unique as an early implementer of Payment by Results and so it is
starting to map activity under the new system but that’s causing problems
already in the current financial year because the commissioned activity that
we’ve placed with [X] is now more expensive and that’s partially to do with
Payment by Results and the tariff… again it still points to the fact that the
information systems are poor… And is it that there’s resistance in the system?
That’s probably why Payment by Results hasn’t gone live. There are actually
secondary providers who perhaps suddenly see that they could lose money.
(Site F: PCT senior manager).
The definition of the interactive Payment by Results of organisations have been
interpreted for this organisation alone, and every other organisation in the
country. Every other acute trust in the country will have gone through this
examination process and maybe some of them have seen the situation, as far
as they’re concerned, remain fairly stable with these different interpretations
and different definitions as various versions of PbR [Payment by Results] have
been issued from the centre but our scenario has gone from almost euphoria to
muted optimism to being downright pissed off.
(Site B senior manager 1)
Interviewer: Why is that? Because of the changing levels of payment or
commissioning?
Yes. PbR, as originally thought, as (senior manager 1) says, it was going to be
used as a very low-cost hospital. As definitions have changed and various
approaches have been put into the system to assist areas of the country which
might have done badly out of Payment by Results.
(Site B senior manager 2)
6.3 Relationships
6.3.1 External partners
Where within the system did the weaknesses that led to the failures in
planning and implementing TCs lie? It was not always possible – short of a
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full-blown inquiry – to gain more than an impression: every level, from
government (as we have seen in the preceding section) through the layers of
the NHS down to the TCs themselves was implicated in many of the sites. We
often found that there had been a lack of collaboration and support from
external organisations in the NHS. Key failures in collaboration included
neighbouring trusts that would otherwise have been treating those patients
(usually because they were unwilling to transfer significant levels of their
activity); PCTs – particularly those beyond the immediate host trust – who
did not choose to commission the expected levels of patient activity (often
because of alternative providers such as independent sector TCs, but also
because expenditure on the conditions treated in NHS-run TCs were not seen
as a relative priority); the ‘host’ PCTs who may not have provided the
expected support; and to some extent the SHAs who were unable to co-
ordinate strategically the distribution of patients between different
commissioners and providers. We will examine here how and why these
relationships failed and later go on to discuss the relationship between the
TCs and their host trusts.
6.3.2 Antagonistic relations
There were several possible reasons why the TCs may have been let down by
these potential partnerships, but sometimes the host trust TC had simply not
put enough effort into wooing and involving these potential partners. Indeed
in some of the sites, as our descriptions of the external milieus of the TCs and
their host trusts in Section 3 will have foreshadowed, the host trust and TC
seemed almost to have deliberately antagonised key organisations. Site A for
example was frequently accused of having excluded the local health economy
from its planning to the extent that neighbouring trusts felt threatened by it
and became hostile (in the case of PCTs these feelings were exacerbated by
their being top-sliced to provide funding for the TC). This attitude made trusts
much less inclined to send ‘their’ patients to a hospital that they believed
might as a result undermine their own viability, or to help find a local
economy solution to the resulting problem of overcapacity.
In local hospitals as well as PCTs there was also a lot of ill feeling about the
way the TC had been set up without involving them in the planning; there
was concern that if the TC succeeded it might fuel ‘predatory ambitions’ and
there was resentment about TCs:
People get very loyal to their organisations – chief execs as well as consultants
– and have not been able to see a greater good. And I think that’s a shame
because I think it’s a fantastic facility. I think it could do a whole load more
work. I think it could probably cover most of elective for the sector. I don’t know
the actual numbers, but it could absolutely cream through a lot. We’d get the
qualitative outcomes if more was going through there and we had a pool of
consultants there all with a subspecialty. Fantastic support for each consultant.
Massive research-base. Great patient outcomes. I hope in time that will be seen
as a resource. But I don’t know why it’s not been perceived in that way. I think
it’s just been seen as the big future hospital trying to steal the work of the other
hospitals, which I don’t think was the intention. We certainly gained from it. I
think patients have gained from it. But I’m not quite sure why the buttons
haven’t been pressed. Maybe they haven’t heard or don’t want to, and they
think we’ve got a bit parochial. I don’t know.
(Site A: senior manager, neighbouring trust)
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Local trusts became unwilling to refer patients because they themselves were
experiencing financial deficits that made it more attractive to use their own
beds to treat patients from a particular specialty. Competing government
initiatives such as Patient Choice and G-Supp sometimes made it preferable
to refer patients to the private sector. Such attitudes and actions left the TCs
floundering. Site F, as will have been clear (Section 3.1) had done almost
nothing to ensure that the neighbouring trusts and commissioners would send
patients to them in preference to all of the other alternatives that were
available. Perhaps their assumption was that their reputation would speak for
itself. If it did, it seemed more to confirm among others their reputation for
arrogance. Moreover the trust’s frank entrepreneurialism led the local health
economy to regard it with suspicion:
The secondary issue which kind of complicates all this is the thing around
activity because a large part of determining a claim was counting things that
had previously not been counted, and counting things in a different way to the
way in which they had previously been counted in order to attract a higher
value invoice. So actually a lot of the work of the PCT was just a bit like getting
a bill from a dodgy restaurant, really, or a dodgy supplier and once you
actually go through the itemised receipt and work out what you’re getting,
you’re not necessarily getting what people say you are getting.
(Site F: SHA manager)
A vicious cycle rapidly developed where the local PCTs and trusts were
reluctant to work with the TC and the TC and its host trust became
increasingly suspicious that the nearby health economies were just looking
after their own interests and sending only ‘rubbish patients’ and were:
...pretty useless really, because of the fundamental premise of people refusing
to send us patients because they didn’t want to lose the income has been the
big stumbling block, and still is. So, the only people who send us money are
those who stand to be so badly in breach, it’s their only way out of a cleft stick.
So, we get sent… people where it’s got to be done in the next two weeks, and
some of them, there’s just junk. Some of it really is appalling.
Interviewer:So they were cherry picking?
Oh yes, I mean on a huge scale.
(Site F: senior clinical manager)
[Patient Choice] patients were coming to us in batches rather than a continuous
stream, so as soon as you get patients coming to you in batches you get
bottlenecks in the system…. It’s completely against the philosophy of a
(diagnosis and treatment centre) where everything is totally predictable and
booked.
(Site F: senior manager)
6.4 Competition and market forces
6.4.1 The lack of a level playing field
Sometimes the explanation for such activity was simple: market forces.
Actors in the local health economies were mainly responding to market forces
and making decisions to maximise their efficiencies that were understandable
in that light. At Site D, for example, the government-led change in
commissioning arrangements, which included practice-based commissioning,
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made it inevitable that the local PCTs would take advantage of G-Supp to
send patients to the private sector because that was less expensive than the
TC. But such market forces, coupled with the pressure to make the best use
of the Patient Choice initiative to reduce waiting lists, did lead to some
perverse outcomes (such as patients being sent to the private sector or even
overseas for operations when these could have been accommodated in
several nearby TCs or other hospitals that were underused).
I tell you, the other day I found out and could not believe it that [nearby
Hospital M] said that through the Patient Choice initiative there is money to
send a certain number of their hip and knee patients overseas, which is just
crazy. You know, we’ve got the capacity to do it, [Hospital K] has got the
capacity to do it, I would imagine [Hospital L] have got the capacity to it – and
you’re sending them overseas!
(Senior manager)
Such consequences might in theory have been mitigated by some kind of
brokering or ‘regulating’ activity by agencies such as the SHA or local Patient
Choice schemes. And indeed at some of our sites, this did happen. For
example at Site A, the SHA eventually helped to provide additional support to
try and minimise the financial deficit. But the SHA were limited in what they
could achieve. Ideally the TC would have liked much more support than was
possible:
The SHA needs to look at what the capacity … is in the system and say right,
either we send a thick, and much larger chunk to [Site A], or we close [Site A],
and it all stays back at the host trust, I think they need to dictate that to a
certain extent, and then say to the trust, right, you need to do, whatever. To be
fair, a lot of the trusts are sending a lot more, but then the PCTs need to also be
told, all the [specialty] work goes to [Site A], and that’s where it’s funded. So, I
think it needs to be a strategic health authority decision, because we can’t go
back to the PCTs and say, no sorry, you have to keep treating the patients,
because if [Site A] treat them, [Site A] want to get paid for it.
(Site A: senior manager)
One of the difficulties facing the SHAs was that they too were undergoing
organisational change in this period, and many were still finding their feet as
organisations. While there were occasional instances of the SHAs supporting
the TCs (for example helping to identify a TC project lead at Site C) there was
little evidence that they were able to provide effective strategic planning or
assistance: as one senior manager explained:
We’ve been to the strategic health authority a hundred times to tell them that
you’ve got to help to market manage this: here is this facility, here are the
waiting lists, this is what you are spending globally… this is bonkers!
(Senior manager)
At Site F the SHA claimed it had tried to be facilitative and supportive, but the
trust would have none of it. They elected not to engage in detailed
discussions with the SHA, whose influence in any case had diminished since
PCTs had taken over the commissioning role:
Well, I think [Site F] probably wouldn’t pay a great deal of attention to us …[…] I
don’t think they see the SHA as being in a position to provide them with a great
deal of anything useful other than some sort of system problems that they
would like us to fix.
(Site F: SHA senior manager 1)
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So far they’ve not really shared that detail because they still see themselves as
fairly unique and not accountable to the PCT or to the SHA; they think that
some of those discussions were only with the chief exec but they didn’t realise
that if they don’t have these conversations with the commissioning process then
they lose out on the opportunity to discuss them in a different way.
(Site F: SHA senior manager 2)
Nor did Site F have good relationships with another crucial mechanism that
was intended to facilitate the ‘market’: the Patient Choice scheme. Patients
had also failed to materialise in the expected way from this source:
They [the Patient Choice agency] are probably not quite sure what we’re doing
and it means we’ve got a relationship where it’s a little bit confrontational. So
much so, actually, that I had a very difficult meeting with their director the other
day who basically accused us of being arrogant.
(Site F: senior manager)
The trust’s failure to link up collaboratively with the local health economy
doubtless contributed to its TC’s demise, although it is by no means clear that
greater collaboration – even had it been possible given the cultural and
economic climate in that part of the NHS – would have averted the eventual
outcome. Nevertheless it is difficult to escape the conclusion that a more
collaborative approach from the initial planning stage with the Patient Choice
scheme – if not the SHA – might have helped prevent the problems from
developing in the first place.
Such a competitive attitude, which contributed to the demise of Site F, was
also seen elsewhere as a necessary part of modern NHS management. The
prevailing view at trust level was that every trust had to look out for its own
future, rather than consider the needs of the whole of the local health
economy. For example:
The strategic health authority in particular, and you’ve spoken to them, have a
real, real mindset of ‘Oh God, we’re going to have [TCs] everywhere!’ and in
particular they’re looking at this scheme and saying, ‘Well, do we really need
it?’ As I say, that’s a decision which is all very well if you’re going to be happy
in a NHS family but it’s a different decision if you’re an independent foundation
trust looking to maintain an income… There’s a problem with being stuck in
oldspeak. It seems to have passed the strategic health authority by
intellectually that we’re a different business model these days. We’re not going
to be one big happy NHS family. We might have been in 1997 but policy is that
we’re competing organisations now and, not only that, we are much more
fiercely competing organisations. It’s completely different. That kind of
opportunity [i.e. building a TC despite potential overcapacity] is compatible with
the policy. They just haven’t grasped it yet.
(Site B: senior manager)
6.4.2 PCTs and SHAs
Nevertheless, despite this marked thrust towards a competitive ethos
between organisations, some TCs did manage to establish good relations with
the organisations in their milieu, especially the PCTs, and this often seemed
to yield positive dividends. At Site C, for example, good links with the main
PCT – both personal and through formal committees – were important to
ensuring appropriate patient flows:
Working has become easier with the appointment of this deputy director of
commissioning. When I started off she wasn’t there so I feel like I’ve got a
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buddy on the other side now and that’s just been really useful. We can just
sit down and thrash it out and work out what we’re going to do. It’s very
supportive and she’s been good news… Those [formal] forums have given some
key focuses around things like length of stay, referral rates coming in, and it’s
always by trust as a whole and then we break it down into referring PCTs.
(Site C: senior manager, emphasis added)
At Site C, as at Site D, some of the new ways of working (see Section 7)
revolved around shorter lengths of stay and more rehabilitation (in particular
physiotherapy for patients undergoing joint replacement). This required
working closely with the PCT managers and clinicians responsible for these
aspects of care, and allaying their concerns:
But I feel that I can appreciate how people who are outside [Site D TC] actually
feel a bit threatened by change. I can appreciate that and they think we’re going
to be sending home all these people who are unsafe to be discharged. This is
what they’re afraid of: that we’re going to make a complete dog’s dinner of it
and they’re going to have to pick up the pieces. I think that’s the bottom line.
They are terrified of that. But the only way we can prove to them otherwise is
by our lift-off period, being particularly careful about that, and also being very
meticulous about our liaison with them and I hope that we will be able to prove
that to them.
(Site D: manager)
However the closeness could be a double-edged sword where, for example,
PCT managers knew the trust managers well enough to observe what they
saw as their failings:
I’m very concerned about capability and capacity at the moment. I observed a
[TC management] team that look extremely stressed out… I think it’s, they’re all
home grown. So, the team hasn’t changed fundamentally… Fundamentally the
people running the organisation were the people running the organisation two
years ago… When you’ve been doing something the way you’ve been doing it
and it ain’t broke, you do have an attitude, why am I going to fix it?
(Site C: SHA manager)
Site E was an example of a TC with good links with local PCTs and SHA, but
to some extent it was easier for them since all parties were keen to reinstate
some kind of hospital facility at that site, and therefore had an interest in
supporting the TC. However, there were some criticisms from further afield
about Site E’s business practices. Some outlying commissioners did not have
such close ties as the more local PCTs; none were represented on the clinical
board and they either dealt with the TC manager individually or through a
brokering trust (for example one PCT in another county bought services from
the TC through their local acute trust). These distant PCTs had mixed feelings
about the usefulness of the TC. Some found it a welcome addition to their
range of providers while others were less positive, feeling disadvantaged in
negotiations related to price and case-mix and consequently preferring to use
services closer to home. They eventually withdrew the contract in favour of
local, more extensive, cheaper provision that had been developed there. Site
E was also keen to work with the independent sector; it sold part of its space
to a private health care organisation and made great play of a developing
partnership, which helped considerably in its financial profile and survival. In
short, the key to Site E’s survival was firstly its ability to forge good links with
potential partners that would supply it with patients, and secondly to be
flexible in response to their needs, not only in the sectors served but also in
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the types of facilities offered (for example moving from day to short stay
surgery).
Site H had mixed relationships with the local PCTs. One of the two local PCTs
was closely involved with TC development, but the other barely knew
anything about it. We found very little understanding locally outside the host
trust itself about this TC and how it was going to operate alongside existing
services, and it was clear that the planning had been very inward-looking at
the TC’s host trust. The managers at the trust justified this by suggesting
that:
PCTs are too new aren’t they? They don’t know what’s happening either. I
mean if you can find anybody in the local PCT who know what a treatment
centre is then you’re very lucky.
(Site H: senior clinical manager)
Site C found itself short of patients when the contracts representing over half
its proposed activity were withdrawn by two (of three) commissioning PCTs.
These PCTs had been unhappy with their usual local provider and had
contracted with Site C. However some way into this process both PCTs
decided to go back to their original provider. This forced the TC to rethink
both activity and casemix:
We’re opening 18 beds on [date] which are going to the orthopaedics and the
other 18 beds are undecided. [In] the original plan that was all surgical, it
wasn’t orthopaedics; so things have really shifted there and when you take into
account that we appointed a ward manager to that ward who was a non-
orthopaedic nurse, because it was going to be a surgical ward, there are some
real tangible decisions that have been made which are an indication that we
could never have guessed just how orthopaedic this beast was going to become.
(Site C: senior manager)
There was perhaps understandably considerable anger and bitterness directed
at the two PCTs concerned, a sense that trust’had been broken. However for a
few people, including one of the senior managers this was just another
setback to be overcome, ideally by focusing on more positive relationships
with the remaining PCT, and developing new links in the wider health
economy. The latter entailed forging links with national networks as well as
marketing the TC more effectively and more widely, and this vision was
shared by one of the SHA managers:
Empower yourselves guys. There’s more than one commissioner out there. You
know, why do we want to put all our eggs in one basket, and actually you
should be really marketable as a treatment centre. If you’re doing things
differently, endorse it, so why are you worrying? You know, get out there and
get the business. So, I’ve been trying to, rather than licking wounds and feeling
very bruised by the whole episode, I’d rather people decide to get a grip and
push forward.
(Site C: SHA manager)
However carefully the TC tried to cultivate relationships they sometimes,
naturally, became strained because of problems they could not have
anticipated. For example at Site G it later became clear that the PCTs would
not be able to pay for the extra work being done as agreed by the TC
(essentially the TC had overperformed and the PCT was overspent). As a
result, relations with the local PCT in particular became very strained and
confrontational over the following year.
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The difficulty over the finances, it’s a nightmare. And that always puts tensions
into working relationships. We had a contract for over performance this year
and it was signed up some time last summer – we’d been over-performing [for
the PCT], really only in the last four or five weeks [PCT] discovered [we] can’t
fake over-performance, worth two, two and a half million. So we now have a
two million problem that we didn’t think we had, which has seriously pissed off
[names mangers] and others.
(Site G: senior manager)
The host trust began actively to market the TC capacity elsewhere with some
limited success. However the legacy of this episode was a continued and
significant financial deficit.
Nevertheless, in conclusion, it seemed that good external relations with the
‘customers’ (PCTs, trusts) and ‘regulators’ (SHAs, Patient Choice) could help
to ensure an adequate flow of patients. Some TCs may have failed to attract
as many patients as they had intended because they had not nurtured the
relationship with the other members of their local health economy. This was a
contributory factor at the planning stage, when a more careful exploration
(and perhaps ‘warming up’) of the likely market could have been discussed,
and the knock-on effects of other forthcoming market developments might
have become clearer. And closer links may also have been particularly helpful
later when the collaborative management of the market that may have been
the best way forward sometimes turned out instead to be impossible because
the necessary trusted relationships had not been cultivated. This in turn was
at least partly attributable to two aspects of general NHS policy: the
encouragement of competition, and the lack of consistency and continuity of
relationships that resulted from the frequent organisational upheavals. But
whatever the background ethos that led to the lack of collaborative networks
in some of our sites, and from whichever side the relationships’ failures
stemmed, the consequence was always detrimental to the TC as an
organisational innovation.
6.4.3 Marketing to potential users
Finally, in terms of external relationships, several interviewees (both external
and internal to the TCs) emphasised the need to pay greater attention to
marketing in order to ensure that PCTs, non-host trusts, GPs and the local
population knew enough about the TC to want to select it as a preferred
provider.
I think there’s going to have to be a lot of training and working with the GPs to
actually encourage them to start thinking a bit more widely as to where patients
may want to go, and if patients actually do want more information it can be
offered, and that it’s offered to patients in a way that they can actually
understand and access as well.
(Site F: SHA senior manager)
Such marketing activity was unusual for those used to working within the
NHS:
What’s been alien to me is, and I’ve worked in the NHS before, that coming here
you’re working for the NHS but you’ve also got to go out there and vie for
patients. You’re competing with other hospitals for patients which in a way is
like a private hospital as well which is not something I’d heard about, coming
here, and that I’d ever have to do.
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(Site A: manager)
In the main, apart from follow up questionnaires to patients who had already
been to the TC, such marketing publicity was carried out using relatively
standard leaflets and websites, with little if any follow up to see how effective
these were. Nonetheless considerable store was set by these activities, and in
Sites A and D this was linked also to their own outcomes research:
When we go to the battleground of the GPs they’re going to want to know ‘if I
send my patients to you what’s going to happen to them?… if I go to them and I
say, ‘well here are the outcome studies from seven thousand patients and these
are our results’, and that will tie in with the new database that’s coming on line
in the next few weeks, and that being our patient satisfaction service. Now, we
used to do it on Excel but it’s very difficult to show the trends of the way things
go and, you know… I mean I can still say, because we know because we still
put them into Excel, that 95 per cent of patients still say that they’ve found that
the service of the hospital are either excellent or good. So we can still say that
but if we can then map that alongside excellent outcome studies then we’ve put
the shebang together in terms of the marketing too.
(Site A: manager)
Site C was perhaps a little more innovative in developing its marketing and
patient information, part of which was based round a custom-designed
cartoon leaflet which subsequently won a national NHS communications
award. In addition to conventional ways of raising its profile, such as a TC
website run by one of the operational managers, Site C developed some
imaginative marketing strategies, for instance setting up a market stall in a
nearby shopping precinct, a strategy also used by Site E. Some of the sites
were also able to use their ‘topping out’ ceremony prior to opening or the
opening itself to market their facilities – often by engaging a celebrity,
politician or member of the Royal family to open the centre, and this (as ever
with such events) was often reported favourably in the local media.
Some fundamental questions arose about the way the public and their GPs
might respond to the opportunity to travel to a distant hospital in order to get
earlier treatment. The assumption that lay behind the government’s Patient
Choice initiative was that they would choose to do so and become more
peripatetic. Yet at least one of our TCs and its SHA believed this to be a false
assumption that had undermined the TC:
The biggest lesson we learnt is that it’s very difficult to move patients around.
Unless you set up a mechanism to direct patients, to signpost patients, to this
alternative hospital, it’s very, very difficult for patients. Because patients don’t
know, and why should they know because they’re like my mother, she never
wanted to know anything about her operation. She said, the doctors know best,
I go and see my GP and my GP knows best, so my GP’s going to send me to the
best place.
(Site F: senior manager)
And what events have proved, I guess, is that it’s actually more difficult to shift
patients around the system than people thought, and patients on waiting lists
are quite resistant to the thought of transferring from one hospital waiting list to
another one. And one can think of the reasons for that. If you’ve established a
relationship with a doctor and seen a doctor in outpatients and gone onto a
waiting list, the thought of transferring to another hospital and having another
relationship with another doctor isn’t necessarily particularly appealing. And, of
course, for the institutions themselves who have got patients on waiting lists,
it’s not necessarily in their interests to give up patients because there are some
chief executives who call their waiting lists forward order books. And if you
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think about it in those terms, it’s the stock of work and the stock of income
which comes in. So I’m not sure there’s been a huge amount of enthusiasm
within the service to transfer patients around because it’s not particularly in
people’s interests and it’s not until you get onto the next stage of choice at the
point of referral that some of those sticky bits within the system actually get
addressed … obviously there’s a relationship with the GP and what the GPs
think about where people should go, and whether they should break tradition or
go with the pattern.
(Site F: SHA senior manager)
Another manager in the same SHA claimed that only 12 patients out of the
waiting list of 2000 said they would actually go to another provider, which
seemed to substantiate this view of market resistance. Yet figures from the
local Patient Choice scheme claimed that out of nearly 20,000 patients who
had been offered choice, over 60 per cent had accepted the offer to go further
afield for treatment. Elsewhere, some TCs – Sites C, E and G for example,
and for a short period Site A – did improve their chances of survival by
successfully bringing patients from very long distances, and were basing their
futures on their ability to continue to do so. Indeed, Site E attracted patients
from afar despite fierce competition from nearby independent sector TCs and
newly-developing NHS facilities. (It should be remembered that NHS Elect
was founded largely upon the principle that patients would travel for
treatment - see Section 5.) An internal report at Site A stated that there
simply were not enough suitable patients in the area to make the TC viable
without going much further afield to attract patients. They tried to import
patients from other parts of the country with mixed success, and the numbers
steadily increased but still fell far short of what was needed for financial
viability.
One of our case studies, conversely, was basing its plans for a controversially
large TC on the assumption that because of the local population’s fierce local
loyalties and low incomes, patients in its area, even if given a choice, would
much rather stay there even if they faced longer waiting times.
It is surprising that with such glaringly contradictory ‘evidence’, TCs (or the
Government for that matter) did not do more to test the real potential for the
movement of patients. After all, that was a fundamental assumption upon
which much of the Government’s model of commissioning was based. Or
perhaps that was precisely why the TCs were disinclined to investigate it.
6.5 Internal relationships
6.5.1 Recruiting key clinicians
Another aspect of marketing was the need to attract good staff to the work in
the TC.
It isn’t just competition for patients either, it’s competition for staff. It’s
competition for skilled staff and [as a way to attract them] the facilities count
immensely.
(Site B: senior manager)
Part of their architectural and technological design task for this TC, this
manager told us, was therefore to make it a really exciting and attractive
place to work: to sell the innovative ways of working, the up-to-date
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equipment, the modern surroundings. Other TCs had experience of similar
strategies:
There are one or two [nurses] who are going to have difficulties in terms of
childcare and travel, and what [M] is doing is she’s working through it with
them because they’re much more biddable than the doctors and they’re trying
to identify ways of being more flexible... There are some issues there with the
nursing staff, but they’re not as big as the issues with the medical staff, and I
think there is a degree of enthusiasm with the nurses. That’s going to be their
new home and they’ve been involved in the colour scheme. I think there is a lot
more ownership with them… The staff, the nurses that I talked to weeks ago,
they all chose to work in [the non-TC hospital], they live in [there]. Some of them
are going to have problems with transport, but they went [to the TC] to have a
look and were absolutely… it does look good, it looks great, and they went
into… and they said, look we’ve got windows we’ve got daylight you know,
they’re working in inside rooms at the moment and there’s so much space, and
oh the patients will love this. It was all positive and I was delighted about that
because their people are going to be there every day, they’re going to have to
travel there every day. They managed see the benefits of it but the doctors
haven’t.
(Site H: senior manager)
Although such a strategy proved effective in attracting key nursing staff who
might otherwise have stayed away, the reluctance of the doctors to travel the
20 miles from one hospital to another remained a thorn in the side of this TC.
Things were different at Site E; after some initial misgivings, surgeons and
anaesthetists from nearby hospitals began to see the attractions of doing
sessions at the TC. This required a good deal of dedicated networking from a
manager seconded from a nearby trust, whose key job was to increase
activity at Site E, but may also have been helped by the local politics being so
strongly in favour of the survival of the TC hospital site. At Site H, there was
rivalry between the two sites on which the acute host trust was based and
some strong initial resistance to the necessary travel that sessions at the TC
entailed. Again this required a good deal of ‘selling’ by the TC senior staff:
I’m already aware of heels digging in the sand to say, we are [Hospital 1]
based, we can’t possibly go to [Hospital 2: the TC site] because we’re very busy
people, and heels are dragging along the lines of, we would really prefer to
have our endoscopy services all in [Hospital 1] and not have them part of this
nice new endoscopy service. We’re just working quietly subtly along the lines of
digging our heels out of the sand at the moment. Like so many things in the
NHS, it depends on a bit of mutual back scratching and A being kind to B and B
being kind to A in return, you know.
(Site H: senior clinical manager)
They succeeded with some groups of surgeons, but some key specialties
refused, citing not only the inefficiency of the travel, but arguments about
clinical safety that were not entirely convincing. The TC had to accept, despite
all the efforts of the senior clinical managers, that some surgeons would
simply not move to the TC hospital site, and that their specialist registrars
would work there instead. As a final example, a board meeting at Site D
reviewed the internal reasons for its predicament and cited six main causes,
of which three were connected with a failure to find staff who would be willing
and able to undertake the new kinds of work expected.
At Site D attempts to recruit key staff were further complicated by the human
resources (HR) procedures and policies of the host trust. Site D was wanting
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to recruit into innovative roles, such as advanced nurse practitioners but the
trust’s HR department refused to recognise this role and the TC were forced to
regrade the post according to existing staffing profiles.
Finally, the strategies used to recruit some types of staff could backfire on the
TC’s reputation with others. One site gained a bad name by relying on
existing networks linked to one particular senior manger to build up a clinical
team. As one staff member put it:
One of the real issues was around favouritism. … they were [name]’s buddies,
it’s as simple as that. And they weren’t all from here, not at all. A large number
of them were from [another hospital]. So if you weren’t chosen to go down there,
you knew that you weren’t one of the guys who were going places
(Manager)
As all these examples show, it was not easy to staff TCs, which was obviously
a problem in establishing this NHS organisational innovation. Apart from
needing to work hard to persuade key professionals to come and work in the
TCs, the innovation also depended on persuading existing clinicians and wider
trust organisation to adopt and to help develop – rather than oppose – the
innovative ways of working that it entailed. We return to this point in Section
7.
6.5.2 Retaining managers
Another need was for good project management to see the innovation
through its various stages from planning, recruiting and training staff,
marketing the new service, to dealing with all the setbacks and so on.
Unfortunately the turnover of senior project managers was itself one of the
setbacks that undermined a number of the TCs. At Site F, to take an extreme
example, there were four changes of project lead between the opening and
eventual closure of the TC – and usually because the person concerned made
a career move upwards on the basis of their contribution to the TC. This
turnover was widely seen as a factor that contributed to the ultimate failure
(that is, closure) of the TC at this site not only because it led to internal
delays in setting up basic systems within the TC, but also because the
constant changes of personnel meant that external links and relationships
were never properly established. Moreover – as we saw in Section 3 – the
senior executives of the host trust did not sustain their interest in the project,
but soon moved on to other priorities, leaving a series of TC managers to
grapple with the major problems that were now besetting the innovation:
I was asked to be involved but it’s been a messy process. It’s been an
incredibly messy process. We’ve had four general managers already. We had
two periods without a general manager. We never had clarity, right from the
beginning, as to the financial streams. So, I’d refused to begin with. I was
asked and I said, no, not until I get the appointment of a manager. We were left
in a position where the whole thing was up and running and just as it started
the GM in place was… basically going to walk away.
(Site F: senior clinical manager 1)
I remember a period when we would ring up [Site F], because I was just about to
go down there and explode one day because things were going so badly wrong,
and we rung up three times in the previous three weeks and got a different
administrator each time who was running it. It does not work.
(Site F: senior clinical manager 2)
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At the other end of the spectrum, Site B, which steadily increased its activity,
efficiency, influence and impact on the improvement to the hospital’s
performance figures, had no significant staff changes in the management
over the three years of our fieldwork. At Site E there were three changes of
chief executive of the trust, which was in chronic financial difficulty, but there
was one TC project manager throughout who retained the authority to take
charge of the entire setting up and running of the TC. This to a large extent
protected the TC from the financial problems of the host trust. When the
project lead finally left (as a positive career move) the trust took the
opportunity to reduce the relative independence of the TC (see below) by
splitting his job into two. One manager was appointed, as it were from the
host trust, and one from within the TC. This allowed both continuity and
realignment, and averted any potential setback caused by the departure of
the person around whom the success of the innovation had revolved.
At Site D the original TC chief executive (who saw himself and the TC as
being separate from the ‘host’ trust) left his post in 2004 and was replaced by
a general manager who now reports to the ‘host’ trust chief executive
(originally the TC manager had been reporting to a board made up of
stakeholders from across the local sector). The fact that the new TC manager
was not designated as the ‘chief executive’ of the TC did not go unnoticed:
one middle manager within the TC commented that as soon as the post was
advertised as a general manager ‘we lose our identity… It makes it harder to
win but doesn’t mean we are not winning’ At Site C the TC project lead, who
had been seconded to oversee the build and operationalisation of the TC took
a promotion which moved him out of the trust shortly before the TC opened.
The departure of this person marked a similar re-absorption of the TC into the
host trust, as the chief executive took on much of the oversight of the final
decision making in the run up to opening, and the day to day responsibility
passed to a more junior, home grown general manager with a nursing
background.
Similarly, at Site A the initial ‘entrepreneurial license’ has now been revoked
and the role of the TC is being continually revised (exemplified by the
departure of the first hospital manager and the clinical director), accompanied
by closer management of the TC from the ‘host’ trust. The original hospital
manager was seen as the:
…right person at the right time. We now need someone different. We’ve just had
an ‘Investors in People’ report down there and it was just amazing: it waxed
lyrical about his leadership style. He was absolutely the right person at the
right time, his background is in the private sector. He’s jolly, and a good
communicator and a little bit anarchic. In terms of the set up [hospital manager]
was a deliverer, it would open when he said it would open and he would get the
patient’s through the door but given the fact that they started from scratch he
did a very good job…but at a cost… He’s another Machiavellian but very
successful but now we need to consolidate.
(Site A: senior manager)
At Site H the original TC manager also left after two years in post and a
newly-appointed ‘service improvement’ senior manager at the host trust took
on the TC-lead. Responsibility for the TC then lay with one of seven directors
reporting to the chief executive at the ‘host’ trust. At Site G the chief
executive and the director of finance who had instigated the idea of having a
TC had both left by 2004. The incoming chief executive had experience of
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championing a TC at a previous site, but perhaps more importantly had a
clear vision of where the trust as a whole should be headed and appeared to
communicate this effectively to staff at all levels across the trust.
Interestingly the chief executive appointment was made after a series of
other key appointments to what was in effect a whole new tier of middle
management at the previously under-managed trust. Significantly two of
these new managers, both directly involved in the development of the TC,
came from outside the trust (and geographical area) and brought with them
what can be described as a ‘business’ ethos, which defined the mission as
making the TC (and the activities of the trust) profitable and competitive.
6.5.3 Other relationships and systems
Finally in terms of internal relationships it should not be forgotten that other
agencies such as architects, builders, supply companies, and hospital support
services such as central sterile supplies departments all needed to play their
parts as agreed, and when they failed to do so, the innovation could and did
suffer setbacks. Alongside these relationships other factors, notably
construction problems at the new-build sites and failures in electrical and
telephony services, provided further hiccups in the developmental career of
the TCs. One difficulty encountered by five of the case study TCs was with the
information systems upon which modernised care was expected to rely.
Site H had planned to use a computerised scheduling system in the TC but
there were problems and delays with this, particularly in relation to the
interface with trust-wide and national systems. They had therefore made little
progress so far with scheduling TC work. Here there was no sense of
innovation being led by information technology (IT), rather, traditional
process redesign would lead any IT developments:
IT isn’t valued very highly in this trust… I think the innovation will come from
lots of the process redesign and then IT and information will be applied to that
afterwards, rather than IT and information supporting the process redesign.
We’ve got so many manual processes within the trust, whether good or bad.
The process redesign will hit on the manual processes and then they’ll try and
fit the IT to that, and then it’s the usual case of well, if you’ve got a bad
process, no matter how you put IT into it, it doesn’t improve the process, it just
makes the process go quicker. So, the innovation I think will be there, but
because of the IT value, I haven’t necessarily been involved in that. So for the
scheduling, it’s a case of if there’s scheduling software out there can we do
anything with it? Well no, there isn’t at the moment, we’ll wait for the national
programme, okay, we’ll leave it. So there may be innovation going on, but from
IMT not very much involvement.
(Site H: manager)
Also in development at Site H was an innovative computerised information
system for following up and monitoring patients in outpatients, which aspired
to provide more concrete data on the success of the treatment (partly as a
way to persuade commissioners of the benefits of using the TC – see earlier
comments regarding ‘marketing’), but at the time of writing this had still not
materialised.
I mean the notion was, and my vision is, that we have a system where patients
are wholly electronically booked into the system where their pathways are
electronically controlled and followed through… So I had a view that for
endoscopy for instance you go for your scope and your records are on screen
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and the minute you’ve had your scope the clinician can do drop down things to
say I’ve done an OP GI [outpatient gastro-intestinal] examination and I found
nothing, blah, blah, blah, and that automatically then, even before you’ve got
back into the lounge to sit down, is on the GP’s system in the notes printed off
so you can take a copy home with you. That sort of electronic system, and the
results, can then be used to – again, before you go home – plan any further
elements of care. So you can schedule and book all of those as well. Now, I
think that’s how a treatment centre should work. The technology hasn’t caught
up. So we’re going to open a TC using old technology and then find it very
difficult to implement new technology. It’s always better when you’re opening a
brand spanking new thing like this, you might as well do the whole thing at
once because people will accept it. It will be much harder to get them to change
after. So that I think is a bit of a sadness that we’ve not quite got there because
of the technology.
(Site H: senior manager)
Site F also ran into various IT difficulties but, typically, saw the blame as
resting with the other organisations with which the TC interacted.
The performance manager just sits at a computer day-in-day-out taking phone
calls from…. [Patient Choice] and from our buddy hospitals and just putting
them on a spread sheet. And even then if you were to ask him the question,
how many people have you seen under [Patient Choice] or under our buddy
system, he couldn’t actually tell you without pulling out loads of spreadsheets
and manually counting them up.
(Site F: senior manager)
I guess the other problem we’ve had which is worth mentioning is the
organisation of some of this Patient Choice stuff has been lamentable and has
caused difficulties for referring hospitals. For example, if I was to say to
[Hospital X] you must transfer more ENT [ear, nose and throat] patients to
[Patient Choice] they would say ‘that’s all jolly good but can you tell me what’s
happened to the patients that we did refer because we’ve not got any
information about those’.
(Site F: SHA senior manager)
At Site E there was a problem of incompatibility between the existing digital
imaging service and the system to be installed in the new (stand-alone)
hospital site. This delayed progress for a while and ultimately required a
different – and more expensive – technical solution. Despite talk of electronic
records and digital imaging, Site G also encountered significant problems,
notably in processing patients from outside the trust catchment area. Here,
there were apocryphal tales of patient notes and X-rays being couriered by
taxi ‘in carrier bags’ from far distant trusts. Likewise at Site A the information
systems were simply not geared up to support the TC activity:
I think that’s, again, one of the biggest problems that we’ve had from the
beginning, is that the hospital PAS system, or whatever you want to call it, is
not really set up to deal with varying trusts sending their patients and then us
giving them information back as to what’s happened to them in as much as
information that they can then confidently take the next step with whatever
they have to do with their patients. So what we do instead is we use the PAS
[patient administration] system just because we have to but we use
spreadsheets, so we’ve got this terrible situation we’ve had for a year of
balancing patients with two systems so that the quality of the data being put in
is questionable when you’ve got two systems going on and we’re managing
patient information with spreadsheets. It’s quite frustrating because, again, it’s
one of those things that you recognise right from the beginning that unless you
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really have a good information system being able to examine your processes
and things you need to be able to vary the type of information you want to get.
(Site A: senior manager)
And at Site C, despite it being an ultra-modern new build, we found that
theatre scheduling lists were still being prepared manually, aided by a variety
of ad hoc individually developed software solutions:
On the information side I collect and collate all the data and it’s on an in-house
theatre system that we’ve had running now for 14 years, which originally was
only supposed to act us for two years. So it’s a manual system so all the data
that we collect has got to be coded manually and printed.
(Site C: manager)
These examples highlight how local technical or financial detail could shape or
alter the organisational innovation that was eventually put in place. An
innovation as complex as a TC, relying on a wide range of key actors could
only be expected to survive if active steps were taken to ensure that all the
relevant factors were properly in place. This was by no means always
successfully accomplished.
6.5.4 The parent trust
TCs had to establish themselves as distinct and reputable entities not only
with potential commissioners, patients and the higher echelons of the NHS
and Department of Health – as well as their own staff – but also with the host
trust. We saw in Section 3 that the TC was often expected to solve the
problems of the host trust. To what extent did they manage to do that and
how did the relationships with hosts develop? It was difficult to avoid an
analogy between the relationship of the TC with the trust and that between a
recently matured offspring and its parents. There were inter-related tensions
over:
• autonomy – the freedom to act independently from the parent
• finance – arguments over money
• help with the ‘family business’
• conflicting attitudes or ethos between parent and offspring
• pride in achievements that reflect well upon the parent versus concern
about failures that backfire on them.
The tensions depended partly upon the character and standing of the ‘parent’,
partly upon the actions of the innovative offspring, and partly upon the
material circumstances in which they both found themselves. These scenarios
played out in a variety of ways.
Site E gradually increased its independence from the parent trust. The
manager of the TC sat on the trust board, (thus strengthening the links and
visibility between the two), but the TC had its own clinical board and other
structures that confirmed this semi-autonomous nature rather than being
fully integrated within the trust. Staff, despite having their day-to-day work
managed in the TC, were also managed by others, at a distance, in the host
trust (for example the trust’s director of nursing had overall responsibility for
nursing staff in the TC but oversight of the specific practices employed in the
TC were delegated to the nurse managers there.) Once operational, the TC
had little contact with the host trust, save through the surgeons who operated
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in the TC and were based in one or other of the trust’s acute hospitals, and
the chief executive’s regular visits, which he told us were designed to show
that people working in the TC should feel part of the wider trust. In general
this degree of separateness was clear, but in the early stages there was some
confusion not least as regards responsibility for the clinical governance of a
facility that did things very differently from the rest of the trust:
That does pose challenges in a lot of ways because, whereas some of the other
facilitators are responsible across the trust, I am based at the treatment centre
and a lot of the services provided within the treatment centre falls under the
management on a wider trust-wide basis. That can be quite tricky, really... So,
that does pose complications at times because I can’t just go off and put things
in place for one area without taking into account whether it’s appropriate. For
some things it is appropriate for [Site E] and the treatment centre to stand alone.
We don’t want to stand in the way of innovation because it is an opportunity to
be forward-thinking and do things differently… It does [feel like an organisation
by itself]. It does a little bit. I think in a way that that was bound to happen. I
think it’s still all clear. I think there’s been confusion over clarity roles, really.
Are they being managed by the general manager here or are they managed by
the head of radiology? And that is quite difficult. I’m not sure the trust has got
to grips with that yet. They’re just evolving as things come up and that has been
an issue with governance.
(Site E: senior manager)
Such uncertainty was quite common among sites where there was a degree of
autonomy; the desire for entrepreneurial freedom fitted ill with the need for
bureaucratic control of publicly funded services. Not only was there a question
about accountability for public funds, but also for clinical governance. If the
TC was allowed full autonomy, then were they also responsible if there was
an untoward clinical event? Or would the trust be held responsible, in which
case could the trust justifiably insist upon keeping some control?
The fact that it was unclear as to what happened to a patient if say the patient
had a myocardial infarction, where the on-call team was, what the processes
were, was something which was highlighted pretty early on. And I think there
was a divergence of view… the PCT view was that what was required was
clear, unequivocal governance in terms of who was responsible for what…
which is what we have now. So I think it all started because there were
questions raised. There were a few questions raised also about drug
treatment…. They could order how they liked. The difficulty was… that’s fine
as long as there were proper governance arrangements, which there weren’t,
and as long as there was clear financial control, which there wasn’t.
(Site D: PCT senior medical manager)
You have the chief executives of each of the base hospitals on a board, together
with other representatives, PCTs and whatever. But then that became difficult.
Again, in terms of fixing it within governance arrangements – the existing
governance arrangements in the NHS – I know… this is even a thing I discussed
with [K] – his view is very firmly – yeah, he wants somewhere where the buck
stops and actually having it under [host trust], at least we know where the buck
stops. It was an interesting debate at the [host trust’s] board meeting, where
there are non-execs… who have not been involved in the process to date. We’re
actually very resistant to this idea, because they wanted a lot of reassurance
that the risk… that they weren’t actually taking all the risk of the centre on. And
the finance director of [host trust] tried to reassure them that, actually, although
the governance fits with [host trust], the buck stops there in that sense – but
there were very firm risk-sharing protocols that new people have to sign up to.
I’m not sure they were totally reassured by that.
(Site D: patient representative)
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After all the key local ‘champions’ had moved on, Site D complained of having
to re-sell the TC concept all over again to the new chief executives of the
partner trusts and of ‘a difficult first meeting’ with them. Although the TC had
been planned since the late 1990s, as late as March 2004 one partner trust
refused to approve proposed governance arrangements. It:
…expressed concerns with regards to ‘accountability’ and why the centre was
not simply a division of [host trust] with service level agreements with the other
base hospitals… specifically asked about the role of executive directors, the
lack of non-executives, the patient forum, the relationship with the Commission
for Health Improvement and the patient involvement processes… The trust
board concluded that is was unable to approve governance arrangements
without further clarification of the issues raised.
(Site D: trust board minutes [host trust])
Eventually these discussions led to the increasing reintegration of the TC with
the parent trust (and the replacement of the TC chief executive with a general
manager – see Section 6.5.2), along with ‘options for reducing the cost of
providing the service [which] should be pursued aggressively’. The TC had
been brought back into line with usual NHS governance arrangements with a
shift to single managerial and financial accountability through one ‘parent’
organisation. A similar shift occurred at all the TCs, where the tensions of
autonomy versus accountability became a concern.
In Site A the original TC manager reported directly to the chief executive at
the parent trust, which caused some difficulties:
He had a direct line into [chief executive of host trust]. For a while I wasn’t
involved at all in this process and [the TC manager] related directly to [chief
executive of host trust] ... bit of a favoured child kind of syndrome and the
others did think, ‘there are no laws, he can do whatever he wants to do’ and
they were jealous.
(Site A: senior manager)
With the departure of the original TC manager and the clinical director, the TC
became much more closely integrated with the parent trust:
Now we have [the chief of orthopaedics at the parent trust] sits on the clinical
board down there and it is much more of a symbiotic relationship. The waiting
list is now managed by [Site A] but there are decisions at pre-assessment that
this patient needs to be seen at [hospital X], this patient can be managed here
at [Site A]. It’s a move from being stand-alone to – I wouldn’t say integrated
quite yet – but there is a clear pathway and it is seen as much more clearly
defined across the two.
(Site A: senior manager)
This is reflected in the new management structure around Site A:
We now have an operation executive [ops exec] that I head up. It’s much
broader base than it was: we have finance in there, acting head nurse,
development director, general manager, clinical director, and a representative
from the complex centre at [hospital Y]… and then we have the [TC] board which
is a stakeholder group with representative. The ops exec was missing… there
was nothing that was driving the business side of things and that’s where the
ops exec comes in. Then the [TC manager] has a senior management group that
sits under that.
(Site A: senior manager)
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Thus – at Site A – the increasingly daunting financial liability arising from the
failure to carry out the expected activity meant inevitably that the host trust
reasserted control over what had been intended as a virtually autonomous
TC. There was a period of somewhat poor relationships and muddled
responsibilities, but within two years the TC’s original ‘entrepreneurial licence’
had been, as it were, revoked. This reintegration into the parent organisation
had clear implications for the TC:
…[before] it was very much an independent republic and [now] it is much more
seen as a divisional directive which has both strengths and weaknesses,
strength in terms of corporate information … We’re much clearer about what’s
going on there and we get the activity reporting and financial reporting, one of
those things is about the way that we do business, the information that we use
in terms of quality here. The downside is that it is now being perceived as just
another division of [the parent trust] and clearly that is not the case.
(Site A: senior manger)
Inevitably the host trust reasserted control over what had been intended as a
virtually autonomous TC.
You have to think of it like a business, you know, no business can survive if we
have another year where we lose the kind of money that we’re projected to lose
this year. We’ve got a deficit of millions and millions of pounds, and the only
way that we can break even, is if this place is full. Partly it’s because we’ve got
a very expensive lease on the building, we don’t own this building, we lease it,
and even if we lock the doors, redeploy all the staff and have not another
patient in here for the next seven years, it will cost... because of the overheads
and the leasing, and whatever. So, that’s madness, so you’ve got to fill it, and I
think they’re right to bang-on about it, because, as you say, I think it is this
conflict of policy. The government has set these policies, and I can see the
sense in setting them, but they clash regularly, and something’s going to have
to give.
(Site A: senior manager, host trust)
Despite increased referrals as some of the local trusts softened their view in
the light of positive experience from their surgeon who carried out sessions at
Site A, the situation continued to look bleak. At the time of writing, the host
trust was still desperately trying to persuade the SHA to step in and convince
local PCTs to send patients to the TC, but sale to, or partnership with, the
private sector was being increasingly considered as the most likely option.
In contrast to Site A, from the very beginning at Site H the TC was clearly
going to be an integral part of the host trust:
It’s part of the trust services and governance will be dealt with in exactly the
same way as it is now and for the rest of the trust. But I think you’re right,
certainly when we dealt with the overseas clinical team up here we had
massive discussions about how we would… issues about responsibility for
clinical governance and how that responsibility is exercised and assurance
given around clinical governance matters, and we set up the scheme upstairs
for instance, which is more akin to a stand-alone treatment centre. We had to
set up specific systems and processes to make sure we had all that in place,
and that worked pretty well. But our treatment centre will be an integral part of
the trust services, so it’s our existing clinical governance arrangements.
(Site H: senior manager)
It seems to have been relatively on line in timescale. In fact, it has come on line
early, which is quite remarkable, I think. Naturally, when you start looking at
the treatment things, it seems as though it is fairly integrated within the ethos
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of the trust. It isn’t some sort of little development that’s sitting outwith, which is
what happens with a lot of them. It’s like something that’s going on in a
cupboard that isn’t necessarily integrated with the whole of the trust strategy,
whereas I think within [the parent trust], it is seen very much as helping to
deliver some of the strategic reconfigurations that have been going on.
(Site H: senior manager SHA)
While Sites B and H had always intended to be integrated with their parent
trusts, it is striking that in all of the other case study sites that had intended
greater autonomy, the trend was inexorably towards normalisation and
increased re-absorption into the ‘usual way of doing things’ in the NHS.
So it was at Site E, where, after the departure of the visionary project leader,
the management was restructured and the TC was drawn back into the host
trust.
So basically the director of operations is responsible for all hospitals now. And
actually that has brought us in from the cold, so to speak, to be much more part
of the trust.
Interviewer: Is that good?
I think it’s good and it’s bad. It depends on which route the trust wants to go
with the treatment centre. If you want to use it as part of your current capacity
to manage your patients out in trust, it’s got to be good because you can only
then improve the way you are using the treatment centre. If you want the
treatment centre to be money earning, go out there, have separate waits, that
sort of marketing aspect, then it’s difficult to do that because what you’ve got to
still then do is use the capacity that the trust doesn’t need and the trust doesn’t
want to turn around and say that capacity is not needed
(Site E: middle manager)
Site C (reflecting its origins as an ‘opportunity’ to expand the new hospital)
experienced a continuing tension between being a separate entity or an
extension of the hospital. As the financial pressures caused by the loss of
anticipated activity hit home, the scaled down TC became more and more
integral to the hospital, with few lingering signs of any particular innovations.
But in Site E (as in others such as Site B which was integral with its trust
from the very start) the reintegration of the TC into the main hospital had the
advantage of making the benefits of the new ways of working more widely
visible, and thus helping to spread their adoption:
A good practice thing that I very quickly picked up on when I first went to look
at their day case area, and also for the inpatients, a small amount of inpatient
activity that’s going on out there, all their patients get a follow up phone call.
That is excellent and it’s something I’m thinking we [surgical directorate at
another part of trust] should be doing.
(Site E: senior clinical manager, host trust)
The TC managers at Site G were struggling from a very early stage to
persuade the host trust to ring-fence the planned-care beds. Although the
trust did agree to this in principle, the high level of emergency admissions
meant that they could not afford to ring-fence the TC beds. Here the TC had
been the beneficiary rather than the leader of a flowering of innovations in
care pathways across the trust, and it soon became subsumed in a much
larger section of the hospital devoted to planned care being carried out
according to the new patient pathways. However, even that vision was
difficult to sustain as emergency care often took priority (and beds): ‘So
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basically,’ as one senior manager described it, because of the overwhelming
problems of the host trust, the TC’s ‘planned care has gone to pot’.
The danger of a TC’s ideals being buried by the bigger problems facing the
host trust was not lost on those trying to establish Site H, and their solution
was to try as far as possible to keep themselves out of view, as it were, from
the quarrelling parents:
I think the way it’s being presented is that this is being presented more as a
reorganisation of existing services [rather than as organisational innovation]. It’s
a reconfiguration of existing services which enables an extension of service in
effect, both in volume and in opportunities for some innovative working… you
may have picked up that there are significant local political difficulties around
[the TC development] So, how things are put across is very delicate ... So, I
think if the TC was on its own without all this political shenanigans around it, it
will be far easier to package… What we’re trying to do is develop this and
deliver a service change without it becoming contaminated by the other politics
and equally without it raising the stakes of the other politics as well. So, to
some extent, it’s quieter than it would otherwise be because of that I think.
(Site H: senior manager)
But this did not allow them to gain the autonomy they were hoping for. The
even more pressing problem was the deficit of several million pounds that
developed in the host trust, which meant that plans to recruit an operational
manager for the TC had to be shelved as funding was removed. But – as the
following example illustrates – the deficit meant that the TC had to ask
permission for many of its essential features, hoping that the outcomes of
subsequent financial negotiations and decisions would be beneficial to the TC:
Basically we did a business case or rather [P] did a business case. He put it to
the trust and they took it to PCT who said, yes, we support this pre-operative
system but we feel that that should come out of your ‘access money’ [funds
ring-fenced by the Department of Health to improve patient access to services].
So in a sense they were giving us the money but they weren’t giving us the
money. But the trust has recognised this will actually… it’s money well spent
because it will reduce the cancellations but even more importantly, really, we’re
giving much better service to the patients
(Site H: senior manager)
At Sites A, F, and D financial deficits – whether in the parent trust or its TC –
resulted in a loss of autonomy for the TC as an innovation. At Site F, the TC
finally reverted to being a department of the hospital (which helped for the
short period before it closed) and, as the external flow of patients dried to a
trickle, focused on using the increasingly spare capacity to get the host trust’s
waiting lists down. Staff, many of whom had not been committed to the
ideals of the TC anyway, were relatively happy about the TC falling back into
the trust like a wave sinking back into the sea:
At least doing our own patients they were known to the staff and so
consequently they were properly selected, properly investigated.
(Site F: senior medical manager)
At Site D, in contrast to Site F, staff were very unhappy about the host trust
trying to wrest back control of the TC because of its mounting debts. Many
felt that the TC’s ‘vision’ had been gradually eroded by the trust, with the
trust taking more and more control, expressed by one manager as ‘loss of
control over how we can implement change’. The TC staff felt that as a result
they had lost some of their unique identity. Moreover, some TC senior staff
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felt that the TC had been doomed from the start because it was born into a
trust that had been struggling to meet the waiting time targets for a long
time: the failure of the TC merely, as it were, symbolised the chronic failure
of its parent trust. (For them, suggestions that the TC might be sold to the
independent sector might not be necessarily unwelcome; they argued in
favour of the private sector ‘to bring diversity and innovation’. Other senior
clinical staff were concerned about ‘selling off the NHS’ and that it was likely
to cause a political furore among the trade unions.) In fact the host trust had
given the TC more latitude for rather longer than the TC’s massive financial
shortfall might otherwise have merited because of the trust’s
acknowledgement that the TC was widely seen as an NHS flagship that would
help to raise the trust’s standing.
However troublesome the environment and whatever problems they ran into,
all eight of the case study TCs had at least some degree of success in helping
their trusts improve their performance against such targets as waiting lists,
as we will see in the next section. But it wasn’t always possible, for example
at Sites A and F, for the trust to acknowledge or celebrate that achievement,
because the TC offspring was also causing the parent serious financial and
other difficulties.
At Site B, it was widely acknowledged that the TC had been essential to
raising the hospital’s profile and local kudos by improving both the quality of
care (new patient pathways and new ways of working) and the quantity of
care (increased throughput). Indeed the new facility was doing much to help
the trust achieve its hitherto elusive performance targets and strengthen the
case for foundation hospital trust status, which was a major goal. But
precisely because the new unit was embedded into the very workings of the
hospital, which was the chief reason for its success, it could not be paraded
as an achievement. There was:
…no glossy building with identifiable presence that a minister can come down
and cut a ribbon on… It has to be glossy and sexy, something you can feel and
hold… The ACAD [Ambulatory Care and Diagnostic Centre] is a wonderful
building, for example which ministers can go to and show off. The same isn't
true of the sort of thing we are developing here. And that presents a
‘presentational problem’.
(Site B: senior manager)
6.6 Achieving targets
To a large extent a TC’s ability to compete and overcome its problems
depended on the degree of over- or undercapacity in its local health economy.
At one extreme, Sites A, F and D were opened in an environment where there
were simply not enough patients to allow them to compete effectively in an
era of Patient Choice, G-Supp or independent sector TCs, (see Section 5) and
the effects were devastating. At the other end of the spectrum, Site B had a
shortage of capacity and little threat from such policy shifts. Somewhere in
between were Sites C, E, G and H, where a combination of marketing and
collaboration with commissioners and providers of health care allowed a more
or less reasonable throughput of patients even though the original planning
assumptions had proven to be misleading. But despite the mixed motives for
opening the TCs and all the difficulties that emerged once they were running,
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most of our case studies were seen to have increased the throughput of
patients and were contributing significantly to reducing waiting times.
For example Site A, for all its difficulties, was nevertheless helping the local
trusts to meet the Government’s stringent waiting list targets. As our
fieldwork was ending, one option appraisal, which included the suggestion
that the unit be closed down, concluded that the TC should be kept open, and
a number of suggestions were made to help limit (and share) the continuing
financial losses. This was based on the view that over the coming two or three
years there would still be a need for at least some of the beds to remain open
in order to continue to meet those targets.
Even Site F, which was eventually forced to close, was able to capitalise on its
unused facilities to make a significant one-off contribution to reducing its host
trust’s waiting list targets. This was probably a temporary benefit of the very
feature of the TC that eventually led to its closure: its ultimately unfillable
spare capacity. Certainly it was not due to its different ways of working, the
average length of stay of patients going through the TC being no different
from the rest of the trust.
In contrast, Site B was struggling with serious undercapacity and the
innovation of the TC was deemed a success from the very start because it
immediately became essential to easing the strain on beds. The TC was thus
allowing the trust to hit many of the targets that it was at last beginning to
achieve, such as increased activity, reduced lengths of stay, fewer cancelled
operations and shorter trolley waits in emergency departments. The
innovation functioned not only as a way of separating elective patients and
shortening their lengths of stay, but also as a capacitor for the surgical
division into which all short stay patients could be placed just as soon as
convenient. Not surprisingly, such a unit was almost never referred to as a
TC. It was led by a dedicated and experienced nursing manager, assisted by a
team of enthusiasts whom he trained to both run the ward and to organise
bed management and theatre lists across the surgical division. By boxing and
coxing with the full complement of beds in this way, the team managed to
achieve over 100 per cent bed occupancy for the whole hospital most of the
time. This entailed a great deal of detailed quotidian activity by the senior
nurses in the team, very tight control of bed usage using easy, friendly,
trusted professional networks across the main wards, and a great deal of tacit
knowledge about surgical procedures, recovery, and individual surgeons'
idiosyncrasies. All the other TCs were also recognised by the wider health
economy as major contributors to achieving not only waiting list targets, but
also providing greater patient choice.
Some TCs also saw the opportunity to work more closely with the private
sector, through schemes – as in Site E – to rent space to independent health
care organisations or even (discussed but not yet agreed at several of our
other sample sites) to develop the TC as an independent sector TC. This had
the potential of allowing those TCs to benefit financially from fulfilling the
government’s targets for up to 15 per cent of all NHS patients to be treated in
the private sector, which their parent trusts saw as an additional benefit.
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6.7 The study sites at the completion of fieldwork
This section has related the story of how the eight TCs in our study evolved,
and we hope that in describing what happened to these sites we have
captured the many and various ways in which they implemented this
organisational innovation. We have revealed how all of the TCs were subject
to poor planning assumptions; the individuals trying to put the TC idea into
operation found themselves unable to accurately predict important variables
such as activity and casemix, partly due to poor data and partly because, for
most sites, the timeframe for this planning was highly compressed. We have
also shown that this planning process was highly contingent both on the
shifting ground of the wider policy context (see also Section 5) and the
external and internal milieus (see Section 3). Good relationships with the host
trust and other key partners were also vital to the development of the TCs.
The failures and difficulties encountered by these TCs, and indeed the
variance between the ideal TC espoused in the NHS plan and the actual TCs
that emerged in the eight sites could be seen as a consequence of poor
planning. However we contend that better planning would not necessarily
have ensured that these TCs came closer to the ideal type proposed by
central Government, nor would it have resolved all of the problems detailed
above. Rather, the evolution of the TCs mirrors organisational innovations
generally (Van de Ven, 1999; Greenhalgh et al, 2005; see Section 10). It is a
highly contingent process, dependent on the interactions of context, history
and relationships, often subject to serendipity or chance events, but
nevertheless following a general pattern.
The stories of these eight innovations continue to unfold: here we simply
summarise the state of play when our fieldwork ended. Of the eight case
study sites selected in 2003, one had closed by 2006, three were examining
or had entered into agreements to selling space and/or capacity to the
independent sector and one had been bought out by a private health care
provider. Three sites remained (partially) identified with the NHS treatment
centre programme. Two of these were, initially at least, relatively small scale
initiatives. By 2006 one of these was subsumed into to larger organisational
project around planned care, but nonetheless was still attempting to practise
the aims and ideals of TC brief (by separating elective and emergency care,
increasing activity and improving patient experience) albeit in highly
constrained financial circumstances. The other had effectively been absorbed
into the host trust while still successfully developing ‘new ways of working’,
but the host retained the ambition, albeit currently threatened, of opening a
much larger, separate TC. Only one of the eight sites appeared to have
weathered the storm, emerging as a stand-alone TC that largely mimicked
the early Ambulatory Care and Diagnostic Centre and exemplified key
elements of the policy model of what an NHS TC should be.
The fact that so few of our case studies managed to create and sustain the
innovation exactly as envisaged by central Government does not necessarily
mean that they were unsuccessful. As we have shown, all the sites were able
to contribute to increased activity and throughput and to the reduction in
waiting times. Indeed the number of patients on waiting lists had fallen by
400,000 and by 2005 was below 800,000 for the first time since records
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began (Department of Health, 2006c). In addition, as the next section will
show, many of the sites were also innovative in developing new ways of
working that led to improved practice.
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Section 7 Improving practice? Evidence of innovation and new ways of working
Whatever the broader issues that were challenging the longer-term survival
of the TCs (Section 6), all of the TCs in our sample had – more or less
explicitly – a group of enthusiasts who generated the momentum and the
energy to try to bring about the necessary innovations and improvements in
care, based on the motivations we have described in Section 4. For them, the
strategic aims of meeting government targets were secondary. In this section
we focus on the ways in which innovations in care were actually achieved,
including changes in both the structure (such as transformations in the
physical environment and in staffing) and the process of care (such as the
application of new clinical pathways).
7.1 Changing practice
It will come as no surprise that those responsible for developing the TCs
needed to invest a good deal of effort in persuading senior staff – especially
hospital consultants – to engage with the new ways of working. We referred
earlier to the importance of ‘idealists’ in the development of the TCs, and all
the sites had such people whose main motivation was to improve – even to
transform – the patient experience. It was not possible to discern any pattern
across the sample that any particular professional group such as managers,
doctors, nurses or other clinicians had a preponderance of idealists. Each
profession had its share of sceptics, pragmatists, opportunists and idealists.
For example, although sceptical hospital consultants were often a challenge to
be overcome, many of the enthusiasts leading the change were themselves
consultants. To a less visible extent, this was also true of nurses and other
clinicians and managers.
Success or failure in that improvement endeavour was dependent upon the
teams’ abilities to make use of the usual features of good change
management in clinical systems including:
• appropriate use of personal networks among colleagues where there was
mutual trust and respect
• harnessing opinion leaders, especially senior respected clinicians
• learning from and building on the experience of success locally and
elsewhere
• understanding and thinking through the motivators and barriers among
key staff, and working specifically to deal with those
• timing interactions carefully to optimise the chances of persuasion
• empowering staff who were already keen to change (novitiate idealists)
• introducing a management framework (for example a modernisation
lead) and structure to facilitate change.
As an example, the group of enthusiasts at Site B steadily overcame the
scepticism among the consultant body by the skilful deployment of strategies
and activities such as those listed above. The TC team there achieved what
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were, for them, considerable innovations in the way clinicians practised, such
as new booking systems and alterations to a wide range of clinical processes,
which were the key to improving the hospital’s performance. This happened
largely because a small group of like-minded innovators were trying to
redesign the way things were done and were using the TC as a vehicle for
driving forward this campaign of change. They did this through informal
encouragement and example but also through formal methods such as
‘process mapping’, exercises in which they tried to include clinical opinion
leaders. The group was supported by being given organisational space and
encouragement (but little resource) by senior management. But mainly the
group relied upon the use of subtle techniques, building on its internal
networks and gradually pulling in more of the senior doctors as allies, to
create a groundswell for change. They succeeded partly because the
hospital’s performance targets and problems demanded it, partly because
they were enthusiasts who want to improve things for patients and staff, and
only coincidentally because of the TC. However the new patient pathways that
emerged from this process were also an essential part of the planning for the
second phase, new build TC.
Clinical opinion leaders, who played such a pivotal role at Site B, were an
important factor at all the sites. When opinion leaders maintained their
scepticism, such as at Site F, where even senior medical managers who were
expected to help lead the change were thought to be against the TC, there
was little change: most doctors continued to feel threatened, unenthusiastic
or even resistant to the TC.
At Site E, opinion even among senior clinicians was provided largely by a
project lead whose vision of the new TC commanded their respect. This vision
was based on previous successful experience of using patient pathways which
matched the opinions and aspirations of the local clinicians. Site E seemed to
have little trouble in persuading clinicians, including senior surgeons, to adopt
the new protocols and pathways that had been developed. There seemed to
be three reasons for this. First there was strong enthusiasm to make the TC a
success, a desire almost to prove the point that the TC would both replace
and surpass the recently closed and much mourned hospital. Clinicians were
fully committed to this idea. Second, the vision of the TC manager was
respected and shared because of his experience in a renowned centre
elsewhere, and the proposed new pathways were easily endorsed because
they were modelled on those he had experienced before. And thirdly, the
pride in the success of the new TC once it was underway at Site E reinforced
the staff desire to conform to its methods of working.
At Site G, the success in innovating clinical practice may have occurred in
part because of the appointment of a group of middle and senior managers
with a strong business ethos, and, later, the arrival of a new chief executive
who had a more open, participative management style. These new managers
brought with them a focus on modernisation and allowed an efflorescence of
innovative ideas that had remained largely suppressed up until then, and
many of which could now be centred upon the TC.
In contrast to Site G, at Site H there was no senior clinician willing to be
identified with the proposed changes, partly because of the local politics of
the split site. But there were several consultants who opposed the change and
made their views known. Progress was therefore slow, and required careful
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tactics of individual persuasion, often with limited success because of a
managerial infrastructure that was unsuited to dealing with the rivalries and
suspicions underlying much of the resistance to change.
The senior managers at Site A, when faced with senior doctors who did not
engage with the new ways of working, were unable to make significant
progress in implementing key aspects of the new pathways, such as pre-
assessment and follow-up. This was largely because Site A did not employ full
time consultant surgeons, but used surgeons from the neighbouring trusts
whose patients the TC intended to treat. This meant that there were relatively
limited chances of working closely with them to inculcate a new attitude to
the process of care. Nor did it prove possible – although it was strongly
advocated in at least one internal report – to enforce the clinical pathways by
making them part of the consultant contract.
Site C appeared to fall somewhere between the extremes of Sites H and G.
There existed reasonably good relations between managers and consultant
surgeons, but the reception given to the TC was strongly coloured by the
clinicians’ expectation (based on the local history) of the likely benefits and
losses to their own practice. Some groups within the hospital felt that they
would probably lose out ‘yet again’ in their attempts to improve their
services, and to some extent managers at this TC backed away from this
‘huge big can of worms’ that remained from the recent hospital rebuild. At the
same time, some specialties saw an opportunity to increase their bed
numbers and operating lists and were therefore positive from the outset.
Managers were able to bring these senior clinicians on board to play an
important role in developing a successful TC.
In short, the degree of success in engaging senior support for innovative
practice in TCs depended on various local political and managerial
contingencies, linked both to the local milieu and to the local motivating –
and demotivating – features of the TC and its host trust. But when it came to
overall success or failure of the TC, the level of clinical support paled in
comparison to the broader strategic challenges of patient flow, capacity and
financial flows (Section 6).
7.2 Changing the patients’ experience of care?
The effects of the TC programme on quality of care were mixed and moreover
often subjectively interpreted because there were few, if any, formal
evaluations of the changes. We describe the impact of TCs on care under the
following headings:
• changes in the physical surroundings
• changes in the process and in particular the introduction of new ‘patient
pathways’
• new roles for staff
• changes in the ethos of care.
7.2.1 Physical surroundings
One immediate, and most visible, difference was the purpose built and
patient-friendly architectural designs that several of our TCs introduced. At
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Sites D and G, for example, patients found themselves being treated in very
modern looking new buildings (which had both been opened by royalty no
less!). Some of our sample sites, despite being part of the NHS, had all the
external trappings of the private sector, and this made them attractive and
popular with the patients who went there. This was especially true of Site A,
which had originally been built as a private hospital.
I think because of the environment… you often hear people walking through the
door and they go, ooh, it’s just like a private hospital…. People do say it’s
extremely friendly, they’ve really been impressed with the care – we ask
everyone to complete a patient satisfaction questionnaire when they leave and
it’s always glowing... And the other thing is it’s really clean and that makes a
big difference. I have never worked in a cleaner hospital and it’s beautiful and
the domestic staff take great pride, it seems to me. And the place is always
spotless and we have no infection and that makes a big difference.
(Site A: clinical manager)
[Patients] want comfort, they want pleasant surroundings, they want clean
lavatories, they want decent food. And that’s what they get here without having
to pay for it.
(Site A: clinical manager 2)
Site E – a refurbishment of part of an existing hospital – quickly became a
showcase for the TC programme, paraded by the Modernisation Agency, SHA
and the host trust as the epitome of the TC concept, and closest to the model
spelt out by the Modernisation Agency (see Section 1, page 12). Modelled
largely on the Ambulatory Care and Diagnostic Centre, it was housed in
similarly splendid and functional new premises. Leather sofas and low tables
furnished the burnt orange waiting areas, pale limestone tiles clad the toilet
walls and floors and light streamed through a glass ceiling, creating a calm
and airy atmosphere.
Every time I go round there there’s a feel of plenty of space and not many
people and yet they are pushing through much more activity these days… It’s
more like walking into a modern library or modern building than a hospital
which is great. All the clinical type areas are hidden behind that façade and it’s
great. The waiting areas for outpatients are very nice, very comfortable and
very modern with the seating. It’s not typical NHS and I think that’s a good
thing. We need to break the mould really of what the NHS currently looks like –
fuddy-duddy.
(Site E: PCT senior manager)
Site C placed a good deal of emphasis on the ‘modern’, clean, state-of-the-art
look and feel of the TC, seeking to match the existing hospital, which had
recently been built under a PFI arrangement. One difficulty arising from
adopting the same look and feel was that many inside and outside the trust
saw this as confirmation that the TC was merely an extension of the hospital,
offering nothing more than extra capacity.
At Site B, where the TC was never described as such and was housed in
accommodation within the main hospital, it was doubtful whether patients
were aware of being in a different unit, as it was simply a refurbished
inpatient ward. There was nothing here to distinguish the ward from the rest
of the hospital; it retained a rather old-fashioned, slightly worn or ‘lived in’
look. This was in keeping with its function since the ward was used not only
for patients who came in for a wide range of routine surgery but also as a
flexible space for patients who no longer needed to be on the main wards
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(known colloquially as the ‘end of stays’). Indeed for many patients, the only
effect of being on the TC that they might notice would be that they were
moved to and from other surgical wards as their condition changed. But the
plans for the second phase of the TC – a new build – were driven by a
different vision that, unlike the present facility which improved throughput
and clinical pathways, would:
[deal] with the quality issue around ‘I’m a patient who’s getting an excellent
pathway in a not so excellent facility’. And it moves to ‘I’m a patient who’s
getting an excellent pathway in an excellent facility’ and that’s my goal, really,
in terms of that redesign. So, it’s not just the efficiency gain with modernisation,
it’s the efficiency gain with modernisation plus ‘God, isn’t this a nice place’ as
well. That’s what patients are interested in.
(Site B: senior manager)
7.2.2 Innovations in patient pathways
The task of modernising the processes of care was pursued at all of the TC
sites and usually resulted in changes to the protocols that included: some or
all of the booking system, the pre-operative assessment, admissions
procedures, a remodelling of the configuration of clinical investigations and
procedures the patient undergoes, and improved discharge planning and
follow-up. See Appendix 6 for an example of a patient pathway.
Site E was regarded widely as a model of such care, and in fact based most of
the redesign of patient pathways on those that had been produced by the
pioneering Ambulatory Care and Diagnostic Centre in London. The director of
the TC consistently emphasised the use of the TC to redesign working
practices not only to provide better care for patients, but also, thereby, to
meet waiting time initiatives, attract and keep staff and also attract patients
from beyond the local health economy to raise its profile (and income), and
also to spread the word about its innovative design and ways of working.
These innovations included the design of administrative pathways for patients
so as to enable a smoother flow from referral through booking and scheduling
to treatment. This was one of the first pathways to be designed and required
the creation of generic clerical workers to support its implementation within
the TC. The pathway was later used in the contract which the TC negotiated
with the independent sector in order to support their clinical pathways. This
example of partnership working between the TC and the independent sector
also produced a model of care that was later taken up by, among others, a
trust in Scotland.
Such changes appeared at all the sites to a greater or lesser extent.
Admissions were booked in advance, sometimes using new electronic booking
systems, taking note not only of the patient’s condition but also their
availability and convenience. Pre-operative assessment was increasingly
carried out by trained nurses according to clear protocols, and including in
some cases a home assessment questionnaire which the patient completed
and returned by post before attending for pre-operative assessment. The
patients’ journey from pre-assessment through their treatment to discharge
and follow-up typically followed newly developed protocols. These protocols
were generally designed to streamline care; they would try to minimise, for
example, unnecessary delays between different stages of the investigation
and treatment, and to reduce the number of different clinicians and others
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that the patient came into contact with. For example, at Site D patient
information gained at pre-assessment and from patient questionnaires was
integral to discharge planning:
So, when I see the patients I will have an opportunity to say, oh, yes, I see
you’ve got 16 steps to your front door. I’ve picked out the red flags and try to
home in on those and come up with, at the end of my session with the patient, a
discharge plan, i.e. whether they feel they’re going to go home with nothing,
want referral to an intermediate care team or maybe just social services or
whether it’s somebody who lives on their own, very elderly, fairly disabled, and
you think, yes, they’re going to need rehab somewhere else, they’re not going to
be a five-day person and at that point refer them to whatever their local facility
is for rehab.
(Site D: manager).
At Site G many of the processes from pre-admission through to post-
operative care were thoroughly overhauled and modernised:
There is a definite sense that things are changing and moving… [B] who was
the waiting list manager, she said the changes had been quite staggering.
(Site G: senior manager)
Such changes at Site G, many of which were in the vanguard of those
proposed by the Modernisation Agency, were not however confined to the TC
but applied to a whole elective care unit (including a new surgical assessment
unit) of which the TC was now a part. They included:
• telephone preoperative assessment by nurses
• changes in skill mix (including new assistant practitioner and anaesthetic
practitioner roles)
• new operating theatre procedures including a linen-free environment
• clinical pathways reducing length of stay (for example knee replacements
in four to five days, hip prosthesis in three days); these were imported
largely from the Ambulatory Care and Diagnostic Centre when a new
senior nurse arrived who had worked there and began working with
clinicians to adapt them for local use
• music in the recovery room
• discharge lounge
At most of the sites it was nurses rather than – as is traditional – doctors who
normally decided, on the basis of protocols that had been agreed for that
particular condition, when to discharge the patients. Follow up would depend
on the clinical need expected for the condition (and not as so often in the
past, on blind routine) and would perhaps be carried out by community staff
working to agreed arrangements. Follow up might also include such
innovations as, for example, a routine phone call from the ward to the
patient’s home.
That’s an opportunity to find out what your patients thought about the service,
their experiences of the service and have they had any problems. You can then
prevent calls going back to GPs from patients that are maybe concerned about
something that wasn’t particularly explained. You can reinforce post-op advice.
(Site E: senior clinical manager, host trust)
Finally, changes also included making more efficient use of existing facilities
such as extending the standard working day in theatres (including weekends
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for elective work) to increase the throughput; or moving patients between
beds, trolleys and waiting or recovery areas in order to free up the space for
other patients in the wider hospital system. Many of these changes involved
the agreement of clinicians to carry out surgery in different ways, such as
doing hernias as day cases or using local anaesthetic.
Very few of our patients – it’s well less than 10 per cent – have general
anaesthetic, so they’re nearly all done under spinal or epidural anaesthesia.
And that means they have good pain control afterwards, it’s easy to keep their
medical condition stable, it also means that we’re able to treat patients that
reflect the whole range of patients requiring this type of surgery.
(Site D: senior medical manager)
As staff became used to the new methods, the list of procedures amenable to
such an approach tended to grow. This was so at Site B, for example, where
more and more surgeons were persuaded of the benefits of working according
to the new principles, such that the capacity of the ward had to be expanded
by the addition of a pre-operative assessment unit to make the whole process
of surgical admissions more efficient. They then began to move some of the
more complex day-surgery to that unit, all of which was designed to make
this short-stay ward even more efficient as a way of dealing with the majority
of routine surgery.
At all the case study sites most of the changes that were described to us were
not particularly new in that the ideas and methods were usually borrowed and
adapted from elsewhere or occasionally from the Modernisation Agency
guidance and learning events (which typically showcased what other TCs
were doing). This suggests a form of innovation that was more ‘exploitative’
of others’ ideas than ‘explorative’. As the following managers at Site A told us
after describing many of the innovations:
That’s the sort of stuff that’s going on elsewhere in the country, so it’s not
groundbreaking.
(Site A: clinical manager)
I guess there is [innovation], as far as we book patients the way we’re meant to
and we admit them on the day of the operation and we use care pathways, but
to me that isn’t radical... that’s the way things should be anyway. If you’re
looking at taking things a bit further and have nurse practitioners doing pre-
assessments or having innovative ways of doing things, we’re certainly not
doing that.
(Site A: senior manager)
Indeed even at any given site, the new procedures may not have originated in
the TC but elsewhere in the host trust. At Site C, for example, teams led
mainly by nurses who were keen innovators (‘idealists’) were developing new
patient pathways in the TC and rolling them out the rest of the hospital but
this work had already been well underway before the TC was even
considered. There had been nurse-led pre-assessment clinics for nearly four
years within Site C’s host trust. Perhaps, then, we should see TCs not as
necessarily ‘creating’ or originating innovation, but rather as prototyping and
field testing it, which may of course be an equally valuable thing to be doing.
As one service improvement manager explained, the use of these
‘innovations’ in the TC could be used as a catalyst for change in the wider
trust/hospital, or simply part and parcel of the wider change process:
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The trust has learnt from the fact that they built this new hospital, we moved in,
and we didn’t change our processes. We transferred old processes into a new
build. It was a huge job moving here. It’s easy to reflect and want to do it
differently but I think the learning has been that for the treatment centre we do
want to try and do things differently… in some sense people could argue that
[the TC] is an extension of the hospital and because it is that far away from the
main hospital we can’t make it completely different. So, it creates a double set
of challenges. It’s not about just making what happens in the treatment centre
right and best practice and leaving the activity in the general hospital area
behind. We’ve got to make both areas and move forward together. Our chief
exec has been very clear that we don’t want a centre of excellence in the
treatment centre and the focus on the main site in terms of improvement to
diminish. Whatever happens in the treatment centre has got to be transferred
over to the main trust, but already in the main trust we’ve got things that are
happening that will be transferable in[to the TC].
(Site C: clinical manager).
The point was that in each site, each new development was, for that TC, an
innovation that invariably had to face local resistance from one source or
another. This was felt most acutely by a specialist manager who was brought
from overseas to manage one of the TCs and who struggled with a moderate
degree of success to increase day surgery to levels that would be quite
normal at many sites in the UK and further afield. Yet locally this was
regarded as almost revolutionary, and the manager found it hard to achieve
for the most mundane of reasons:
He gets very frustrated at the pace of change within the NHS, and he’s also
been heavily involved in theatres, because that’s his background as well,
…getting things started on time, and encouraging nurses to take on slightly
more extended roles, so they can scrub-in, or assist, or whatever, and then …
looking at the restructuring of pre-assessment, and outpatients.
(Site A: clinical manager)
Usually the tensions between the ‘idealists’, the ‘sceptics’ and ‘pragmatists’
ensured that many sites not only experienced, as we have seen, mixed
success but also ambivalence in the very introduction of the changes
expected by the modernisation agenda. At Site C, for example, as the TC was
increasingly constrained by the wider financial and political problems of the
host trust, one of the ‘idealists’ was still required to work on a programme of
redesigning pathways and staffing. The work was having very little impact,
especially given the TC’s now very small size:
I was part of the treatment centre project and look at role redesign. So, I was
contracted for two days a week for six months, which finishes at the end of this
month, to work with the treatment centre team. I have to say it’s been quite a
frustrating experience which culminated in me going to see [L] and saying I’m
struggling, really, because the message I was getting was we don’t need
workforce redesign, we’re just going to have more of the same and everything
will be absolutely fine.
(Site C: senior manager)
Site D was committed to the introduction of new pathways modelled on its US
‘mentor’ organisation, but ran into serious tensions and difficulties with a
number of influential consultants over the introduction of the advanced nurse
practitioner role, on which many elements of the pathways relied, such as
pre-admission and ward cover. Site F’s introduction of innovative patient
pathways was, as we have seen, dismissed by many of the consultants as
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unsafe or unworkable (despite the success of similar pathways elsewhere in
the country) on the grounds that very few patients fitted the ‘bureaucratic
template’. That view in Site F had more or less prevented change, but at
other sites similar views were not sufficient to block the innovations. A senior
surgeon/manager at Site B, for example, had started out as a TC sceptic but
upon retirement had been persuaded to do a number of day surgery lists.
Progressively he became a ‘pragmatist’ convert and a stalwart of the new
pathways, helping to develop a pathway for hernia repairs. But nevertheless
he was keen to point to its limited scope:
It’s more or less a transcription of what happens anyway really. It’s a little bit
streamlined, speeded up, although it’s most probably done, at least partially,
with the smoothness of the operation in mind rather than – I don’t mean the
surgical operation, I mean the whole thing – rather than the patient… But if the
patient doesn’t fit the first box, nobody’s interested… The trend is to identify
within the whole morass of the health service bits that can be cleaned,
identified, counted, costed and get on with that. Day surgery, treatment centres
coming in, the cancer work being centralised, just because it’s a good idea
clinically to have the expertise but because it’s a way of dealing with it that is
more uniform. The worry is what’s left and how that’s going to be managed.
(Site B: senior clinical manager)
At Site H a major stumbling block over pathways centred on consultants’
reluctance to give up control of their lists as required by a redesigned booking
system, although the manager responsible for encouraging the change
recognised the validity of some of the clinical arguments and altered the
staffing accordingly. There are several features to note in the following
example:
• the persistence of the local politics and rivalries between the host trust’s
two hospital sites’ methods of working
• the struggle for control over the system for choosing and admitting
patients; the potential wrecking power of the consultant body
• the perceived strength of the clinical argument; the deference of the
managers on clinical issues despite their scepticism about some of the
consultants’ motives
• the pragmatically negotiated solution to allow the innovation to move on.
But above all it is worth noting how the sheer mundane familiarity of such
contested, negotiated order, such as can be found in almost any hospital on
any given day, was an integral part of the detailed design of the treatment
centre – in this case a new clinical staff member to schedule operations:
The surgeons are very much more in control and they will seemingly – in some
cases arbitrarily – pick patients off who haven’t been waiting very long and put
them before patients who have been waiting quite a long time. In their minds
there must be some reason for it. I mean it’s not just that they’re urgent, but I
think there are a couple of issues. Control is definitely one of them. They want
to be in control, they don’t want the administration to be in control. They see it
as a clinical issue and I think that’s a valid point… Historically [Hospital 1 at
Site H] has had the waiting list office which booked all patients, whereas
historically here [Hospital 2 at Site H] the secretaries control the lists, and there
has been huge resistance to having a centralised waiting list function. And
there’s lots of good reasons for that, not the least of which is that at the moment
there isn’t anybody clinically qualified working in the waiting list office. So, a
lot of the time there are mistakes made because the staff don’t actually
appreciate what they’re doing when they’re putting a list together. Now, one of
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the things that I have insisted on is that in the treatment centre the schedulers
are overseen by somebody who has clinical qualifications. So there’s like a
scheduling manager type of person who will be clinically qualified, preferably
theatre.
(Site H: senior manager)
A further example from Site H shows the pragmatic way in which decisions
needed to be made about the design (and resource implications) of another
innovation. In this instance some local investigation into the causes of
cancelled operations revealed a key factor for the success of the TC whose
solution – a pre-operative telephone call – then depended crucially on further
complex negotiations for additional funding:
When [R] did his work on cancellations, the majority of cancellations are
actually day cases. We imagined that we were going to find out that bed
pressures were going to be the cause, and it wasn’t that at all… There was an
equal proportion of DNAs [patients who ‘did not attend’] and medical
cancellations, whether they were the patient decided that they didn’t need the
surgery anymore or the doctor decided but decided on the day, because of
course they hadn’t been seen. So the idea of this redesign service is that in the
case of day cases, if they are straightforward then they get a phone call two
weeks before they’re due to come in. If for some reason they’re not coming, then
they won’t ever go on and somebody else can go on. If this doesn’t get approved
as a business case, it really will be a big blow to us, but there’s no funding.
This is the problem. That wasn’t something that was going to be funded by the
PCT for the treatment centre
(Site H: senior manager)
In the event, the TC did not secure funding for this idea because of the
financial deficit of the trust, which led to a vacancy freeze.
Other sites faced with a similar problem of unsatisfactory selection of patients
for the TC (either by their own systems or by the PCTs or Patient Choice
schemes that referred the patients) arrived at different solutions to the
problem. Site G used this as an opportunity to push the boundaries of
surgical practice, for example by allowing patients with complex co-
morbidities to undergo day surgery:
And we’ve probably pushed the limit… the criteria, a little bit, with the
[surgeons]. Because they have actually done an insulin dependent diabetic
through the unit, which is a no-no in this country… And they actually saw the
patient in pre-assessment. So they rang me up and said, rather send this
patient to [another TC] he can be done as a day case, he’s quite happy to come
in here. I said, yeah, fine, bring him in next Monday. We did it and he was fine.
Blood pressure dropped a bit but his diabetes was not a problem. We’ve
managed a couple of others that… a brain tumour, which they [normally]
wouldn’t touch. There was a stroke patient… They’ve actually seen the patient
over in their pre-assessment clinic and they couldn’t see any reason why, as
long as you manage them correctly, with the anaesthetic, that you shouldn’t do
them through the day surgery – and we’ve done them… We’re broadening that
criteria for entrance into day surgery, [but] a lot of the criteria at the moment for
day surgery are very strict.
(Site G: senior manager)
Several sites also faced problems with scheduling and standardisation, often
because the IT systems were not geared up to cope with the transfer of
patient information between different trusts/hospitals (see Section 6.4.1).
Occasionally there were problems when it became apparent during the
operation that a patient required more complicated surgery. For example at
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Site G this necessitated a transfer out of the TC into the main elective care
wards:
One of them had to be admitted – not because of her problem but because when
they actually did the operation – it wasn’t what they had planned to do. … I
think when they actually incised and actually saw the extent of the operation
that was required and they felt that it would be better if she didn’t have fixation
in her toe to straighten it. …you’ve got to put them in bed, really, so we had to
keep her in for two days.
(Site G: senior manager)
Where did new pathways come from?
As well as describing the improvements to practice we were interested in
understanding how knowledge (evidence) and experience informed the
introduction of patient pathways. As the forgoing discussion has indicated,
some of these pathways were borrowed from external sources – other
pioneers of new ways of working. Thus at Site E, a decision was made to use
patient pathways developed for use at the Ambulatory Care and Diagnostic
Centre. It appeared that there was little dissent from the local clinicians in
adopting these new practices, which were ‘trusted’ as having good
provenance and championed by the TC manager (who was in turn respected
and trusted). The fact that the new pathways corresponded with the
clinicians’ own views of good practice also ensured that there was little
resistance to their incorporation in the routines of the TC.
Site C initially went along a different route, attempting to develop its own
patient pathways. Indeed considerable effort was expended by nursing staff
in particular in trying to develop pathways which in essence took apart
current practice for each procedure and attempted to reassemble it in ways
that improved the patient experience and streamlined care delivery. About six
months before the opening date for the TC a decision to use generic pathways
was made and the team working on integrated care pathways (ICPs) changed
direction: the extended field note below captures some of the debate around
these new pathways at this time:
The chair of the inpatient group meeting asked about ICPs, ‘what were the
timescales?’ Gwen [a senior administrator] circulated a document showing the
various ICPs under development and said that they had ‘had a bit of a
breakthrough last week in developing a generic day surgery ICP’ they were now
hoping to use the generic day surgery ICP as template and slot in ‘specifics’ for
other procedures. Previously the group working on the ICPs had tried cut and
paste and taking bits from other ICPs but then they ‘sat down and did the
generic one from scratch’. This pathway lends itself to arthroscopy and hand
surgery so will be sending adapted version out to ask for comments from the
clinicians involved in these operations. The group will then tackle the task of
writing a generic ‘inpatient’ ICP. While all this discussion was taking place I felt
there was a sense that much of the earlier work on ICPs was made redundant
by this move to generic ICPs, but that no-one around the table really wanted to
articulate this. However, one of the nurse managers did point out ENT [ear,
nose and throat] had done considerable work on a tonsillectomy and nasal
surgery ICP and that the meeting had to be ‘careful’ dealing with this, not to
make them feel that all this work had been wasted. After some further
discussion about the generic ICPs Joe asked, ‘as a manager I want to see how
this place is working differently. What does it do differently as a result of all
this?’. Gwen responded that they were ‘looking at what best practice is and
trying to incorporate this into ICPs’ – so that the result would be ‘not quite
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standardised care but that someone coming in now and someone coming in, in
three months’ time would get the same level of care
(Site C: researchers’ fieldnote).
At Site B various forms of evidence were used in the design of the TC, both at
the broad strategic level and to assist in the redesign of specific clinical
pathways. Such evidence was largely based either on their own experience or
that of respected colleagues elsewhere (and a reliance on such colleagues
being knowledgeable about best practice either through contacts or through
the journals) and on other sources such as journals, websites and
professional associations as these collected quotes illustrate:
We did look at evidence. People have looked at the Middlesex [Ambulatory Care
and Diagnostic Centre] scheme. We’ve also looked at our own [day surgery]
centre and we’ve got evidence before our very eyes, which is really quite
helpful. We’ve discussed with the people who are doing [mentions four nearby
hospitals that are designing TCs or day care units].
(Site B: senior manager)
I must admit I don’t trawl through the literature looking for those things.
Perhaps I should but I don’t… We do our own audits and when we’ve done an
audit we look at research but I don’t personally trawl the literature for that sort
of thing. [Interviewer: But you work on teams that do these redesigns: does that
team ever delegate somebody to go off and find out what such and such
essentially does?] Yes, I’m sure they do because there is a regional committee
that will, a regional radiologists committee that we all meet and there’s a similar
superintendents group, I believe, that meets and the path of national
benchmarking exercise we’re aware of what goes on.
Interviewer: So there’ll be a lot of information sharing, pick up what’s going on
in the grapevine and all of that?
Uhuh. What we have is informal structures because the registrars rotate round
and they come here and say, oh, by the way, do you know that they do it like
that down the road and that sort of informal information gathers.
(Site B: hospital consultant/senior manager)
Actually to be honest, a lot of the ideas for the hernia pathway came from
[nearby hospital]. We used a variation of that… but that didn’t come out of me
sitting round with colleagues from other hospitals.
Interviewer: How did you do that?
I can’t remember. It just came through an informal sort of nursing network,
someone that knew someone that was working on it. It’s something that I have
asked the strategic health authority whether they could facilitate that getting
them together, because people who do my sort of job are quite comfortable with
that. Other areas can be a little bit more competitive, but there is an element of
competition between the two teaching hospitals in one city.
(Site B: nursing manager)
What we’re trying to do now is get all the evidence-based practice from other
areas to support that.
Interviewer: What kind of evidence?
Well, going onto websites to look at who else might be doing a pathway that’s
like this, to have a look at outcomes and things like that so that we can say Mr
So And So and such and such a hospital is doing it this way, they’ve seen such
and such a percentage increase in throughput, it’s just finding out that
information.
(Site B: manager)
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Contact with the British Association of Day Surgery has been vastly important
because they kind of explain the basket [term coined by the Audit Commission
in the 1980s to describe the group of operations feasible for day surgery]; they
underpin the work that’s gone on. They present the papers. They present the
kind of work that’s gone on in different trusts around the movement of
inpatients to day cases and those procedures have not just been picked
because they’re there, they’ve been picked for a reason. They’ve been piloted
and tested and satisfaction has been looked at and outcomes of patients and
clinical and satisfaction have been looked at and it’s good…It really is good. It
actually gives a very balanced view because it will equally listen to nurse’s
views as well as medics’ views as well and I think that body has become a very
important body in the development of day surgery.
(Site B: hospital consultant/senior manager 2)
She [a nurse manager] is responsible for putting together some of the [TC]
protocols and I asked her how she went about it. For example she has done the
one on angiography. She said she pulls together the evidence by talking to the
consultants. Most of them have got different views about what patients can be
discharged when, and what the criteria are. She also looked at the journals for
evidence – the journals of day surgery, and one on anaesthesia. But when I
pressed her, what she was looking for was published discharge protocols from
other centres that she could draw upon. That seems to be what she was calling
evidence. It was notable that she made no mention of critical appraisal, trials,
systematic reviews, or any such matters promulgated by the evidence-based
practice movement.
(Site B: researcher’s fieldnote)
7.2.3 Innovations in staffing
Many of the new pathways entailed making changes in clinical roles, which
itself entailed breaking down some of the traditional distinctions between
existing professional groups. At Site A, for instance, there was some blurring
of professional boundaries, with nurses trained to do post-operative
physiotherapy and therapists trained to review GP referral letters in order to
triage and investigate patients, and to decide if they were appropriate for the
consultant to see. At Site B, the trust hoped to introduce a new grade of
health care assistant who would be a relatively junior nurse, and who shared
many of the roles of an operating department assistant, for which that
assistant could also train. They held other, more ambitious, ideas such as the
introduction of non-medically trained anaesthetic assistants in abeyance until
there was more evidence of success elsewhere in the NHS and the local staff
doctors might be more receptive to the idea. Site E, like others elsewhere,
developed pre-operative specialist practitioners with responsibility for pre-
assessment, and also advanced theatre practices by using two theatre
practitioners (one a nurse and one an operating department assistant) to
undertake minor procedures for example taking prostate biopsies. They also
introduced more flexible use of skills such as using nurses to rotate through
theatres, recovery and the short stay areas:
In order to cope with the peaks and troughs through the working day, as well as
over periods of time you need to capitalise on the transferable skills of nurses
in theatres and recovery... The skill is to look after an unconscious patient
regardless of whether that’s in theatre or in recovery
(Site E: senior manager).
Site D was initially envisaged as a nurse-led facility, and to this end the TC
originally intended to be innovative in the ways that the nursing workforce
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was used. This included the appointment and training of some 20 advanced
nurse practitioners with the idea that these individuals would not only push
the frontiers of nursing practice forward, but also that they would have an
educative role in developing other key staff such as therapists and health care
assistants. As one of the managers explained, this new role would provide a
new opportunity for nurses:
And the clinical nurse specialist [at another hospital] was so frustrated because
she wanted to do so much, but her patients only just couldn’t do it, because she
didn’t have the resource. But here, at the brand new centre, it’s just a real
opportunity to be able to do so much more ... We’ve been fighting for
professional status for so long and to be able to take over what the doctors are
doing and to be at the forefront, delivering what nurses haven’t done before –
we’ve got fantastic nurses. And if you go speak to any new advanced
practitioners out here, they’ve also got the bug and they just think it’s great.
(Site D: clinical manager)
Sometimes – due to a variety of factors including scepticism and resistance or
an insufficient drive for change from interested professional groups – the
crucial block to the innovations was the failure to achieve those necessary
alternations in staffing patterns, including changes in the balance of different
grades and the introduction of new roles that crossed traditional boundaries:
The place has been staffed in a very traditional way. I would describe the
nursing skill mix as very top heavy – lots of E grades and a lot of F grades as
well as G grades, so it’s been quite traditionally set up. In theatres they want
lots of E grades, there are very few theatre surgical assistants and ODAs
[operating department assistants]. And why it’s happened that way I think it’s
just happened that way, I don't think anybody’s given it an awful lot of thought
to be honest.
(Site F: senior manager)
Resistance from defensive professional groups was not the only bar to the
introduction of the new clinical roles. There was also the problem of
resourcing the new model, either in terms of finance or the recruitment of
appropriate personnel. At Site D, the original plans had been formed some
years earlier, still with traditional staffing in mind, but – at the time the
opportunists saw the chance to implement those plans as part of the TC
programme – the innovative idea of nurse-led care was enthusiastically
embraced as a new focus of those plans. Unfortunately, the concomitant extra
funding was not. The rationale was to have been that it would use fewer
junior doctors, resulting in savings from which the new nursing grades could
be resourced. However these rather loose calculations were superseded by
the need for those funds to be used as a means of motivating senior doctors
to use the TC. In other words the funds saved by employing fewer junior
doctors were spent on paying senior doctors, not on developing new grades of
senior nurses. Added to this reduction of resources was a problem in the
funding of the intensive care unit that was linked to the TC; a problem that
was chronically exacerbated by its being unexpectedly underused. Thus the
innovative staffing ideas, as well as some of the intended innovative
equipment and associated upgrades, were severely compromised by a lack of
money. Given the emotional investment in the new advanced practitioner role
and the importance of the nurse-led identity to this site, exemplified in the
earlier quote from the clinical manager (above), this lack of investment came
as a heavy blow for the nurses at this TC.
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Recruiting and training personnel for the new roles was also often a problem,
as the following manager succinctly illustrated:
One of the main things I’ve looked at is how the health care assistants or the
nursing assistant role can expand because we’re under demand to provide
theatre systems for the theatre team. They’re demanding our experienced staff
to actually fit that. If we do that then we’re going to be depleting our scrub staff.
So, we need to address it from the bottom up then hopefully we can help those
experienced staff to take on an extra role and if we look at the theatres at [host
trust] we’ve got 18 new operating theatres. If you only wanted one member in
each theatre trained up then that means we’re employing 18 additional staff
and [yet currently] we’re having [unfilled] vacancies of between 25 and 30.
Now, that’s not realistic. So, what we’re looking at is other ways around it
really. We don’t have a problem recruiting nursing assistants or HCAs [health
care assistants] so therefore we can train if we want to in part and it would be
like a rolling programme. We could recruit into these posts and as they become
more experienced and we can put them on the skills escalator to achieve those
additional competencies.
(Site B: clinical manager)
Thus, even when they had everyone’s agreement, the strategic intentions of
new staff grades, without which the innovations within the TCs could not be
maintained or developed, required very detailed operational manoeuvrings.
Moreover, such internal shifts occurred in the broader context of schemes to
recruit people to nursing – such as the re-establishment of a ‘massive’ drive
to recruit ‘cadets’ in the region concerned, an associated revamping of the
qualifications ladder from school leavers through to qualified nurses, the
development of new curricula and assessments, new gradings and salary
scales linked attractively to other career ladders such as operating theatre
orderlies, and so on – and all this in the broader context of economic and
demographic trends that were impeding recruitment to the health care
professions at every level.
The shortage of suitable personnel – in this case surgeons – to undertake the
required work for TCs led two of our sample sites having overseas surgical
teams flown in to do regular operating lists, and these did succeed in
attracting highly qualified surgeons from abroad. At one of the sites, this
seemed to produce constructive mutual learning with overseas surgeons
interested in sharing knowledge and techniques, but also learning from their
NHS counterparts. While viewed positively within the trust, the arrangement
was not without its critics, however, for example from at least one surgeon
from further afield, who objected on principle to having patients sent from his
waiting list to a distant unit to be operated on by ‘foreign’ surgeons. The
other site using overseas surgical teams, which had already used such teams
before the TC opened, found that the experience helped persuade some
sceptics to see the relative advantages of ‘factory’ type surgery. The
successful experience of having foreign doctors not only provided evidence
that the trust could take on these types of projects, but also lessons for the
design of the TC:
I think we’ve learnt as well because you may have heard that last year, last
June to September we ran on this site upstairs here ..[an].. overseas clinical
team, and that was very much on the basis of – if you like – it was a sort of
treatment centre for [specialty] surgery and we could see the advantages of
doing that, but also the significant disadvantages. I mean there are advantages
of throughput and efficiency, but the issues of continuity of care pre the surgery
and then post the surgery were really major, and it opens up some serious
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questions, for instance around the [Patient] Choice initiative and moving
patients between services. The fear is that the loser in that situation is the
patient who gets a discontinuity of care and certainly what my feeling is we
should look and try to avoid that discontinuity of care through our treatment
centre. It should be integral with the rest of the care that patient’s receiving.
(Site H: senior manager)
One of the workforce issues picked up early on by the critics of TCs was the
potentially negative impact of these centres on surgical training (Section
4.1.3). The pressure on TCs to increase activity and throughput was seen by
some commentators as a bar to undertaking training in this environment (the
argument being that the presence of trainees would slow this activity).
Professional bodies such as the British Medical Association argued that the
removal of routine work from the mainstream of hospital activity would
diminish the training offered to junior surgeons, both by removing the less
complicated procedures (on which the very junior trainees might begin to
learn) and decreasing the overall number of training opportunities. As we
have intimated (see Section 4) not all our case study sites took the view that
training was precluded within the TC: indeed Site C welcomed the
development of the TC as a chance to promote training. Given the relatively
high profile of the debate about training in the media and professional
reporting around TCs it was striking that this issue was not discussed more
either in interviews or when we were observing the TCs. The one foray into
this territory we gathered was this view, from a regional workforce manager
linked to Site A. This respondent was concerned about the potential impact of
the TCs on medical training:
It’s based on the premise that you’re taking elective work out of surrounding
hospitals. Therefore it affects, in theory, the experience that junior doctors were
getting in training within those hospitals. And, indeed, the most noticeable case
was [hospital X], who planned to move their entire orthopaedic elective over to
[Site A]. The questions they asked were, if we do this, what happens to our
training great doctors, i.e. will they lose approval [as a training site] because of
the change in the clinical experience?
(Site A: workforce confederation manager)
7.2.4 Different (‘can do’) mentality
Finally, in terms of the innovative care being delivered in the TCs, it is
important to stress that there were often units where the front-line staff did
cultivate a different, and very distinctive, ethos from the rest of the hospital .
At Site B, for example, staff were clearly focused on getting patients through
the system efficiently, and fiercely proud of their reputation for innovation
and flexibility. Although this TC was integrated with the rest of the hospital,
its innovative ways of working coexisted comfortably with the more traditional
attitudes elsewhere in a trust which, according to TC staff, lacked its own ‘can
do’ mentality:
The TC ward manager/sister… told me how they had been trying to transfer a
patient and the main ward wasn’t able to take them. ‘What’s the hold up?’, we
said. ‘We haven’t got a bed made up’, they said. ‘Right we’ll come and make
the bed for you’ which we rushed up and did straight away and that way
everybody’s happy
(Site B: researcher’s field note)
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In this and many other ways, TC staff tried to ensure that their philosophy
was understood and appreciated by the rest of the hospital. This kind of ethos
often engendered a feeling of almost euphoric belonging among front line TC
staff, which ultimately linked to much greater – and real – ‘patient-focused
care’:
It’s exciting! We’re not standing still. There’s lots going for it and there’s a great
future. And I see it expanding greatly. I think that is very good for us, the
people, and everybody.
(Site E: theatre manager)
That’s why I say we’re special because we give [patients] information what they
want, where other clinics don’t. There’s ‘next, sit down, wait for your number’.
But we don’t do this. We have a personal relationship with the patient… We do
a little bit extra than we need to do… I chat to my patients, I don’t just make it a
formal interview. It keeps them calm and relaxed and they enjoy the experience,
and that’s what we want. We want a DTC [diagnosis and treatment centre] to be
an enjoyable experience… We sort out the social problems here. I had a case
yesterday where I had to sort out this 80-year-old in a wheelchair who lives on
the fourth floor in a flat without a lift. He’s come for a knee replacement.
Surgeon comes to me and says can you sort this out for me? I had to sort out
the housing scheme… you see that’s part of my extended role.
(Site F clinical manager)
For some staff the development of the TC was also central to their own
personal or career development, nowhere more so than at Site G where the
project to get the TC off the ground represented a unique opportunity for
some relatively junior staff to develop project management skills. The small
team who managed the early development of the TC exemplified the ‘can do’
mentality – summed up neatly by one middle manager (who incidentally had
worked her way up the career ladder having joined the trust several years
previously as a clerk):
You can’t expect to sit back and let things come to you. Sometimes you feel they
should, but more often than not, you have to go out and get, you have to go out
and find it. No one else will help you deliver – you have to do it yourself.
(Site G: middle manger)
We are not in a position to determine how far individuals like this self-
selected into positions linked with the TC, but it is clear that the TCs did
provide important developmental opportunities. It is worth noting that we
rarely found examples of disillusionment or defeatism. The one example
which counters this view of a ‘can do’ mentality comes from a nurse manger
at Site C, which had undergone recent relocation to a new hospital build: for
this individual the TC represented yet another change at a difficult time, and
at too great a speed:
There’s no additional time. There wasn’t any additional time last time round
either and there definitely isn’t this time and that does cause complex… When
planning for the treatment centre everything seems to have had quite short final
times, like 24, 48 hours for some things. I got back from two week’s holiday to
be told, ‘I’m coming up in an hour to sign off some drawings!’. To me that has
felt really quite rushed and potentially quite risky compared to the timeframes
we had last time.
(Site C: nurse manager)
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7.3 Summary: the struggle for a glass half full
In chronicling the formidable challenges that local TC managers faced as they
struggled to overcome traditional mindsets and ways of working, one begins
to put the scale and scope of an innovation such as this into perspective. To
some observers the changes we have described may appear fairly small-scale
and undramatic, almost routine (‘first order’ improvements rather than
‘second order’ transformations) but from the view allowed by the case studies
– and from where the innovators themselves were sitting – we can begin to
appreciate just how ‘revolutionary’ and hard-won the innovations often were.
It is important as outsiders not to underestimate what was achieved – and
seen to be achieved – on the ground.
As this section has shown the TCs were seen as bringing about real change
and improvement in the way patients were treated, for example in better
scheduling and throughput, or in the protocols of care that patients
underwent. However it was also clear that there were different perceptions of
that change process, particularly in relation to the scale and degree of
‘success’ of innovation. For example in one site we heard from one senior
manager that:
There has been no innovation around staffing, recruitment and process. Looking
at other types of posts, you know, we don’t have a nurse consultant, we don’t
have a nurse specialist, we’ve got pre-assessment clinics being run by
consultants. … It’s all very traditional. Theatres are exactly the same – a very
nursing, top heavy skill mix… there has been little thought as to what
operations are we going to do and therefore what skills do we require and does
it have to be a nurse – there hasn’t even been that sort of line of questioning.
(Site F: senior manager)
Yet, in contrast, two other clinical managers from the same site told us that:
They [patients] love the clinic, they really, really do. The reason why is because
they come in, they get all the attention, they see everyone they need to see, we
do everything on them that we need to do and work with the outcome – a day
for the operation, or for the six month follow up… Some patients call it a one
stop shop because it took the patients 52 steps to get to surgery, whereas it
took us two steps. I think it’s a very grand, very posh clinic… I bring in plants
as well and make it friendly for patients. And I’m busy doing the reception area
as well. I’ve put some plants in there, and I’m going to get paintings and hang
paintings. So it doesn’t look like a clinic, it looks more like a living room. What
we try to do is play classical music as well because it makes people calm.
(Site F: clinical manager)
At least you’ve got a decent, clean, fairly new ward that can work as a day
case unit. That’s something; it’s better than nothing at all.
(Site F: senior clinical manager)
Although it was not within the remit of the current study to provide a
quantitative assessment of the extent of change ‘achieved’ by the TCs,
remarks like these allowed us to reflect the views of those ‘on the front line’
of making these improvements to practice. Here at Site F it appeared that
there had been little major change in the attitudes of senior clinical
(especially medical) staff, and that attempts to introduce formalised patient
pathways, which had made little impact on lengths of stay for elective
surgery, had often been ignored by the doctors, who continued to rely on
long-established procedures for pre-operative assessment, admission and
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discharge. Nevertheless, even here, we could see that the introduction of the
TC resulted in a marked fall in the waiting times for many operations, and
nurse managers also made considerable strides in improving the patient
experience before the unit was forced to close for lack of patients.
At Site H, where the TC was still developing when we finished our fieldwork, a
disappointed service improvement manager told us that the TC had not done
anything ‘really innovative’. Yet our impression in comparing their
achievements with some of the other case studies was that this site was
much more in tune with the modernisation agenda than most; the project
manager had worked a good deal with the Modernisation Agency, had
rescheduled and relocated elective care, introduced patient pathways, hired
visiting teams of overseas doctors who had helped reduce waiting times, and
was now spreading some of the new practices further across the trust.
Latterly the key barrier to further developments in improving practice was the
financial crisis of the host trust which put a halt to further expenditure around
modernisation and/or redesign.
At Site A there was considerable clinical pathway development work, but
(perhaps because of the failure to engage the surgeons most of whom were
employed elsewhere and worked as visiting specialists) managers believed
there to be relatively few innovations in the actual surgical care that was
given. However they also admitted that this was difficult to judge because
there was no benchmarking against which to compare other services or the
parent trust’s own status quo ante.
Here I think that there are certain things that we now take for granted, as
normal practice if you like, whereas when I go to other places, they go ‘ooh,
that’s a good idea!’ and I think, ‘oh that’s really basic to us…’ So I think we are
still innovative. I don’t think, if I’m really honest, we’re not always as innovative
as we like to think we are… But having said that, we’re making a lot of
changes, in terms of day surgery, getting regional blocks, and sending patients
home without any alarms, and so there is a lot changing, but it’s changing, it
hasn’t necessarily changed.
(Site A: clinical manager)
As a final example of the problem of assessing the impact on clinical practice
of TCs with such mixed fortunes, Site D claimed in one communication that:
The innovative treatment and the high standard of care that [patients] receive at
[Site D] will continue and further improve… [Site D] is already a local centre of
excellence. By allowing an independent provider to manage these services, [it]
can become a world-wide centre of excellence. [Site D] will continue to treat at
least the same volume of NHS patients and all local people will still have the
choice to be treated at the centre.
(Site D: press release)
Such claims – which were of course part of a campaign to justify the
involvement of the private sector in the face of some fierce opposition – were
not far-fetched. Yet this TC remained in serious operational difficulties and
had an uncertain future. Despite all the problems (see Section 6) of poor
planning, overcapacity, financial setbacks and the evanescence of the
principle of nurse-led care, there were some remarkable changes in the type
of care that patients received here. These included a pre-operative
assessment done by nurses via a questionnaire, a nurse-led clinical pathway
about which patients were supposed to be fully informed before arriving at
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hospital, well-honed individual care pathways with key milestones (based
albeit controversially on US models), case managers in charge of discharge
planning, PCTs providing planned intermediate care, and considerable
redesign of the workforce in order to accomplish these new ways of working.
On balance, then, the view from people working in and around the TCs was
mixed, albeit broadly positive. Some saw (and were proud of) changes they
had made to the delivery of care. Others were frustrated at the incremental
nature of change and had hoped for more radical transformations which they
felt were yet to be realised. Our sense as outsiders is that many of the
changes we have described in this section were indeed incremental. They
represented small, often low level changes to ways of working, adaptations
and continuations of change processes already in train, often borrowed from
elsewhere or developed within the host trusts. But we should not ignore the
fact that what may be first order to an outsider may feel very much a second
order change to the insider. And they nonetheless represented some marked
improvements to practice.
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Section 8 Quantitative studies related to treatment centre operation
Alongside the qualitative evaluation of TCs, part of the SDO project proposal
concerned the application of mathematical modelling methods to examine
aspects of TCs in relation to quantitative issues such as patient throughput
and capacity. This quantitative work accounted for a relatively small part of
the project budget (15 per cent). However, in the event, far more was
achieved than was originally envisaged, at no additional cost. Such are the
vagaries of research in mathematics.
A good overview of the core of the quantitative work may be obtained by
quoting from the original proposal:
The intention is to use mathematical modelling based on stochastic analysis
techniques, using methods from probability theory to describe the flows of
patients through their treatment pathways. This has parallels with a branch of
operational research concerned with the analysis of queues. Such stochastic
methods allows the analysis to take account of variations in factors such as
length of stay, variability in the scheduling of admissions and non-
homogeneous case mix within a particular unit. Such methods have already
been exploited successfully in relation to the analysis of booked admissions
(Gallivan et al, 2002; Utley et al, 2002a). These recent studies have highlighted
the central role that the variability of length of stay has on capacity needs. The
more variability there is, the higher the capacity needs (since one cannot base
bed planning simply on average needs). The introduction of [TCs] provides a
potential mechanism to counter this. Although length of stay is variable from
patient to patient, there are some factors that can be used to distinguish
between patients likely to have a longer length of stay and those whose stay
will be shorter. Such factors include the procedure being performed, the
patient’s age, existing co-morbidities and whether the admission is emergency
or elective. Given this background, the research team recognises that whatever
their other merits, [TCs] have a particular attraction from an operational
research perspective in that they present a means of exploiting a particular
feature of the ‘economics of scale’ that has not been feasible within traditional
NHS hospital structures.’
This very much describes the quantitative research that has actually taken
place within the project. By good fortune, early on in the project, a discovery
was made that allowed the application of powerful techniques from the field
of mathematics known as optimisation theory. This meant that, when
considering inpatients, a unified approach could be adopted to deal with the
complex interactions between capacity, length of stay variability, case mix
and booking decisions. This will be the main focus of the present section.
The operation of outpatient services does not have the same scale of
complication related to length of stay variability, although it does of course
play a part. However, there are still difficult planning issues that have to be
resolved. Again it was found that methods from optimisation theory could be
applied.
These streams of research very much address questions related to providing
analytical tools to help to improve the operation and planning of TCs and
these will be the principal topic of the present section.
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As outlined in the passage quoted above from the original proposal, the
quantitative researchers have also investigated questions associated with
economies of scale in relation to the use of capacity. Here, there is a trade-off
between increasing capacity in non-TC centres, thus benefiting from
economies of scale, and the potential benefits following from better
management of length of stay variability that might follow from introducing
TCs or increasing their capacity. From an SDO viewpoint, the emphasis of the
research question thus changes from ‘how can one make a TC operate
better?’ to ‘under what circumstances is the introduction of a TC an effective
use of capacity?’. This issue is an order of magnitude more difficult to address
and of course should not be seen in isolation from other more qualitative
issues associated with TCs. Work on this is discussed in Section 9.
We are aware that some of the mathematical modelling that has been carried
out is rather technical in nature and full details of this would probably be
unpalatable to many of the readers of this report. Fortunately, most of the
key findings are contained in peer reviewed papers that have been either
published or accepted for publication (Gallivan, forthcoming; Gallivan, 2005;
Gallivan and Utley, 2005; Utley et al, 2005; Utley and Gallivan, 2004). Here,
we shall avoid mathematical detail as far as possible and restrict our
attention to summarising the main findings in non-mathematical terms.
Where explicit formulae are given, a ‘cartoon’ style is adopted with the
implication that a precise understanding of the technical detail of the formula
is not a necessity on the part of the reader and all that is needed is
reassurance that such formula exist. Also, on occasions we quote passages of
text virtually verbatim from these, our own, publications.
8.1 Background – the key role of variability in determining capacity requirements
Scheduling and queuing are both complex matters that arise in a wide variety
of contexts including manufacturing processes, telecommunications and
transport. ‘Operational research’, the mathematical field that covers such
matters has shown that, if a system is operating close to capacity, small
changes in the way in which a system operates can have major knock on
effects. For example, well-intentioned changes to the strategy used to control
the traffic lights in an urban road network can, if the system is operating
close to capacity, result in gridlock.
Does this have any relevance to NHS operation? Certainly the NHS is a
complex organisation and at times appears to operate close to capacity. An
uncomfortable question arises. If the NHS is indeed delicately balanced close
to the cliff edge of overload, is it conceivable that the introduction of new
mode of operation, such as TCs, might actually degrade performance?
Drawing parallels with traffic control, there are three key factors: reserve
capacity, unpredictable variability and blocking. The interaction between
these has a major impact on the efficient operation of the health service and
various operational research studies have investigated such issues (for
example Millard et al, 2000; Worthington, 1991; Harris, 1986; Shahani,
1981; Harper and Shahani, 2002; McClean and Millard, 1993, 1995; Bowers
and Mould, 2002, 2005; Costa et al, 2003; Mackay and Millard, 1999; Bagust
et al, 1999; Bensley et al, 1995; El-Darzi et al, 1998). Surprisingly, in
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practice, NHS managers seems to pay relatively little attention to the
variability of length of stay. Equally, it is uncommon to keep records related
to constituent parts of a hospital episode, such as the time spent in intensive
care or in a high dependency unit.
In an earlier paper (Gallivan et al, 2002) we discussed the central role of
variability in length of stay on capacity requirements, illustrating this using
an example based on intensive care following cardiac surgery. The notions
discussed in that paper are central to the analysis underlying the present
work so it is well worth restating them.
A common (and erroneous) method for estimating bed capacity needs for a
unit is illustrated in Figure 2.
Figure 2 A conveyor belt model often erroneously used to estimate bed capacity
needs
Unfortunately, while such a simple model seems appealing, it is erroneous
and indeed very misleading since it takes no account of variability.
We devised a mathematical model to examine the effects of variability of
length of stay on capacity requirements of a post-operative cardiac intensive
care unit in the context of a booking system for cardiac surgery. The model
was based on the use of probability theory. As is common with mathematical
modelling, many of the complexities of real life hospital operation were
neglected, the purpose being to examine the principles underlying the
process. Within the model, it was assumed that a regular and unvarying
number of operations are booked each day, each performed successfully, and
each resulting in a patient being admitted to intensive care for post-operative
recovery. Patients were assumed to remain in intensive care for a whole
number of days, the duration of their stay having a pre-specified probability
distribution. Patients were assumed to be homogeneous in that the same
length of stay distribution applies to each. Lengths of stay were assumed to
be independent of one another and also independent of the number of beds
occupied. The specific length of stay distribution used was based on real data.
The histogram in Figure 3 is derived from the mathematical model and
indicates the probabilities of different numbers of beds being occupied. These
are calculated from the number of cases assumed to be booked each day and
the distribution of length of stay. The histogram is centred on the number of
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beds that would be required if there were no length of stay variability. The
tails of the distribution occur as a consequence of the variability in length of
stay. If by chance, a group of patients are booked whose post-operative care
requires longer than average, then more beds would be occupied. The upper
tail of the distribution indicates the probability of such an occurrence.
This mathematical model starkly illustrates how variability poses a
fundamental problem associated with booking and bed capacity provision.
The average length of stay was 1.65 days. Since five operations per day were
assumed, this corresponds to an average requirement of 8.25 beds. Ignoring
variability in length of stay, an eight-bed or nine-bed intensive care unit
would seem appropriate for this level of bed requirement. However, variation
in length of stay means that operating an intensive care unit with eight beds
would lead to operational overload 41 per cent of the time (for a nine bed
unit, this figure would be 22 per cent – see Figure 4). Increasing the number
of beds to give reserve capacity would be the only option. However, to reduce
the chances of operational overload to 5 per cent or less, then as many as 11
beds might be required. In capacity terms, this would correspond to
maintaining a unit with over 30 per cent reserve capacity. This is clearly
possible, but expensive.
Figure 3 The distribution of bed demand derived from the mathematical model
discussed in Gallivan et al (2002)
Number of beds required
16151413121110987654321
Probability
.25
.20
.15
.10
.05
0.00
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Figure 4 Modelling the probability that there is a booked admission but no bed
available dependent on the number of beds available (taken from Gallivan et al,
2002)
To make matters worse, this initial mathematical model was deliberately
simplistic, the philosophy being that a booking system that fails to operate
effectively when applied in simple circumstances stands little chance when
used in the real world. The mathematical model used in the British Medical
Journal article (Gallivan et al, 2002) was designed to illustrate a point of
principle – that variability in length of stay complicates the policy of
admissions booking and gives rise to increased capacity needs. The model
was not intended as a tool to be used for planning purposes (although it
would certainly be more realistic than using conveyor belt estimates) in view
of many factors that had not been taken into account.
Later work (Utley et al, 2003) extended the model to include other key factors
as illustrated in Figure 5. In addition to variability in length of stay, this
allowed consideration of issues such as ‘did not attend’ (DNA) rates,
unpredictable emergency admission rates, and patterns of admission booking
that vary according to the day of the week.
Figure 5 Modelling bed capacity needs taking into account multiple sources of
unpredictable variability (based on Utley et al, 2003)
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Somewhat surprisingly, even though several complicating factors had been
introduced, it was found possible to derive explicit, although quite complex,
mathematical formulae for the mean and variance of bed demand and how
these vary during the week.
8.2 Example: the use of modelling in treatment centre planning
It is useful at this point to consider how such modelling could be of use to a
health care manager. The example discussed in Box 1 concerns an actual
planning problem that the authors were asked to help with. Although the
planning problem discussed arose as part of this study, it does not relate to
one of the formal case study sites discussed elsewhere in this report. The
account given is based on that given in Utley et al (2005).
Box 1 The setting
The example concerns one stream of clinical activity in a TC housed within a larger
acute hospital. The TC manager had reached agreement with the wider hospital
management concerning the level of patient throughput that the TC unit should
deliver. This level of activity was largely influenced by the number of general surgery
procedures that would be required to meet Government targets concerning the
maximum waiting time that patients should face. At the time of the planning exercise
described in this section, the TC manager had agreed on an operating schedule with
the available general surgeons and was in the final stages of arranging anaesthetic
cover for this schedule and planning post-operative care facilities.
The questions the manager had to answer were:
1 What level of bed capacity is appropriate to cater for expected demand for post-
operative care?
2 To what extent are bed capacity requirements affected by a predetermined cyclic
pattern of admissions for surgery?
3 To what extent are bed capacity requirements affected by unpredictable variability
in patient post-operative length of stay?
In this simplistic statement of the problem, the focus is on the provision of
beds. It should be noted that along with the physical resource of beds, this
planning problem also relates to the attendant level of nursing cover that is
required for post-operative recovery and many other resource issues such as
equipment requirements and demand on hospital catering.
8.2.1 Planned theatre activity
The planned theatre activity was determined by the TC manager in response
to two key constraints:
• the number of patients that needed to receive an operation within the
planning period required in order for the organisation to meet
Government targets relating to maximum waiting times
• the availability of general surgeons and anaesthetists.
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After negotiation with surgeons and anaesthetists, the TC manager decided
on the weekly schedule for theatre activity relating to general surgery given
in Table 3 below.
Table 3 The repeating weekly cycle of the planned number of general surgery
cases
Day of week Number of patients planned
Monday 6
Tuesday 6
Wednesday 8
Thursday 8
Friday 9
Saturday 0
Sunday 0
8.2.2 Length of stay distribution
The exact distribution of length of stay for patients was not available since
this planning was being done before the new service came into operation, and
thus direct observational data were not available. Also, it was considered
unwise to use length of stay distributions for patients from another hospital
setting, since the new TC service was intended to treat only routine cases
which was expected to have the effect of curtailing the length of stay
distribution. An estimated distribution was constructed by the research team
in conjunction with the TC manager and the hospital's information manager
to reflect the ‘realistic target’ length of stay for surgical patients. Since the TC
planned to select patients deemed less likely to have an extensive post-
operative recovery, the shape of the distribution was chosen to have less of a
‘tail’ than is typical for post-operative care in traditional hospital
environments. The distribution chosen for use in generating planning
estimates is given in Table 8.2.
Table 4 The post-operative length of stay distribution used to generate the
planning estimates of post-operative capacity requirements
Length of stay (days) Proportion of patients
1 36%
2 47%
3 10%
4 5%
5 2%
It was assumed in this case that the length of stay for all patients using the
TC could be approximated using this distribution. It was also assumed for the
purposes of generating the planning estimates that patients could be
discharged on any day of the week, including weekends, and that patients'
length of stay was not affected by which day they received surgery. Although
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this might be an unrealistic assumption in some hospital contexts, weekend
discharging is one change in practice that is being encouraged within TCs.
8.2.3 Results
The mathematical model outlined in the earlier parts of this section was used
to calculate the distribution of requirements for post-operative care beds,
based on the data relating to length of stay variability and patient admissions
given above. These calculations were performed using a Visual Basic for
Applications routine written by the authors to implement the model within the
Microsoft Excel spreadsheet environment.
Distributions of post-operative bed requirements
As the number of patients undergoing surgery varies throughout the week,
the distribution of bed requirements is different for each day of the week.
Figure 6 shows the distribution of bed requirements for a Monday and a
Friday respectively.
Figure 6 Distribution of bed requirements on (A) a Monday and (B) a Friday
based on length of stay and admissions data given in this section
To summarise the results, we plotted for each day the mean bed
requirements and the upper 95 percentile of bed requirements. The graph
showing the weekly cycle of bed requirements is shown in Figure 7.
Bed requirements on a Friday
0
5
10
15
20
25
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Number of beds
Percentage of days
Bed requirements on a Monday
0
5
10
15
20
25
30
35
40
45
50
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Number of beds
Percentage of days
A
B Bed requirements on a Friday
0
5
10
15
20
25
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Number of beds
Percentage of days
Bed requirements on a Monday
0
5
10
15
20
25
30
35
40
45
50
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Number of beds
Percentage of days
A
B
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Figure 7 Mean post-operative bed requirements and the upper 95% limit of bed
requirements for each day of the week
Evaluating a particular level of post-operative bed provision
The distributions of bed requirements presented in the previous section were
calculated using the assumption that no operations would be cancelled due to
a shortage of post-operative beds. These results can be used to explore the
likely impact on the TC of providing a given number of post-operative care
beds. This is done by using the calculated distributions of bed requirements to
calculate the proportion of days when requirements would exceed a given
capacity. This provides an estimate for the proportion of days on which the TC
would face operational difficulties whereby extra post-operative beds would
have to be provided to avoid the cancellation of scheduled operations. For the
current example, Figure 8 shows the proportion of Fridays on which bed
requirements exceed capacity for different levels of capacity that could be
provided. To highlight the folly of basing capacity plans on average lengths of
stay, the capacity corresponding to average bed requirements is marked.
Daily bed requirements
0
5
10
15
20
25
Mon Tues Wed Thurs Fri Sat Sun
Day
Beds occupied
Average
Upper 95% limit
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Figure 8 The percentage of Fridays on which demand exceeds capacity for a
range of possible operational capacities
Note: The dashed line shows the capacity that corresponds to average requirements.
These estimates proved very useful to the health care manager concerned,
who used the results to lobby within the host trust for greater provision of
post-operative beds within the TC.
8.3 Extension of modelling to better reflect the context of treatment centre operation
The problem presented by unpredictable variability is not so much the
variability as the unpredictability. If one can somehow predict variations,
system design can take account of this and compensate. For example, we
know ahead of time that winter months bring an increase in admissions for
respiratory conditions. This is predictable variability and sensible planning
takes account of it.
TCs are intended to be less prone to the effects of unpredictable variability.
Emergency admissions, a major source of unpredictability, play little or no
part in the operation of most TCs. Booked admissions systems have been
shown to reduce patient non-attendance rates (Kipping et al, 2000). There is
also some scope for TCs to select patients thought likely to have a more
predictable stay in hospital. In addition, novel working practices in TCs are
thought likely to reduce variability between patients stays still further. All of
these factors tend to reduce unforeseen system variability, which is beneficial
from an operational viewpoint. That said, some variability in length of stay
between patients is inevitable, for example due to different treatment
requirements of patients with different diagnoses or due to within-group
variability.
This section concerns both predictable and unpredictable variability in length
of stay and discusses how knowledge regarding these can be used to assist
those planning TC services. One problem facing planners relates to estimating
Percentage of days demand exceeds capacity
0
20
40
60
80
100
10 11 12 13 14 15 16 17 18 19 20 21 22
Bed capacity
Percentage of days overloaded Expected demand = 16.8
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capacity requirements to honour booked admissions for a given number of
patients with differing needs. This is inextricably linked to the question of how
one should efficiently schedule admissions from different groups of patients
taking due account of predictable variability in length of stay between the
groups.
Technical details of our mathematical modelling are given in Gallivan and
Utley (2005). Here an overview of its principles is given. We model the
operation of a single unit which treats several categories of patients, each
category having a known length of stay distribution. Different forms of
variability that are taken into account are illustrated in Figure 9. Although TCs
do not cater for emergency admissions, allowance is made for this possibility
so that the same form of model can be used to model non-TC operation.
When modelling the operation of a TC, the expected emergency admission
rate is simply set to zero.
For convenience, we regard these categories of admissions as being different
health related groups although other classifications are feasible. We assume
the unit operates a cyclically repeating pattern of booked admissions with a
planning cycle of fixed length, typically a week.
Given this simplified representation of the operation of the unit, the
admissions planning process centres on choosing the number of patients from
each health related group that are booked for admission on each day of the
planning cycle, bearing in mind that there is no particular reason why this
should be homogeneous from day to day.
Figure 9 Elements of model developed for analysis of TC operation taking
account of case mix and cyclic booking patterns
Depending on the cyclic pattern of booked admissions adopted, the mean and
the variance of the number of beds required during each day of the planning
cycle, are also both cyclic. Further, using probability theory, it is possible to
express these as exact formulae (see Gallivan and Utley, 2005 for full
details), as shown in cartoon form in Figure 10.
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Figure 10 Explicit analytical expressions for the mean and variance of bed
demand dependent on cyclic pattern of booked admissions (apparent
complexity camouflages simple dependence of expressions on the decision
variables)
The reason for departing from our custom of avoiding the statement of
explicit mathematical formulae in the main text of the report is that these
formulae have particular importance. Their discovery, which was unplanned,
meant that rather more could be achieved using mathematical modelling than
was expected. The relevance of these formulae is that they express key
aspects of a hospital’s operation in very simple mathematical terms. Although
they may look complex to a non-mathematician, in view of multiple
summation symbols, in fact the algebraic form is particularly simple. These
formulae are equivalent to stating that the mean and variance of bed demand
on a particular day can both be derived in terms of linear combinations of the
numbers of different types of patients booked for admission throughout the
planning cycle. Admittedly the coefficients in these linear formulae are
somewhat fearsome, but computationally it is straightforward to calculate
what these coefficients are.
While it is mathematically pleasing that such a simple mathematical formula
should have been discovered, there are more important consequences than
aesthetics. The exciting consequence of the finding was that, since the
formulae for bed demand have a simple linear form, then they are neatly
amenable to being exploited using a range of very powerful analysis
techniques from a field of operational research called optimisation theory. Not
only that, but there are also analytical techniques related to the control of
traffic systems that can also be used to assist their analysis (Allsop, 1972).
As a consequence, even though there may be many millions of possible
admissions patterns, powerful optimisation methods can be applied to guide
this choice (Williams, 1993), as used by Adan and Vissers (2002) in relation
to scheduling hospital admissions in the case where there is no uncertainty in
patient length of stay. Computer programs have been written to compute the
mean and standard deviation of bed demand, to use these to derive estimates
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of the upper 95th percentile for bed demand and to carry out optimisation.
Figure 11 summarises this approach.
Figure 11 Exploiting techniques from optimisation theory to determine booked
admission patterns that maximise reserve capacity during the week when the
number of beds available remains fixed
Again it is useful to use an example (in this case hypothetical) in order to
illustrate how these methods could be useful to those planning the delivery of
services within a TC. Consider an orthopaedic TC with 32 beds admitting
patients from two health related groups: arthroscopy and primary knee
replacement. With only two groups, this example is somewhat artificial and is
not intended to show the benefits that improved admissions scheduling might
bring in practice, more to illustrate the point of principle.
The length of stay distributions we assume are based on information taken
from the Hospital Episodes Statistics database (see www.hesonline.nhs.uk)
and have been truncated at 14 days to reflect the fact that TCs are intended
to deal only with routine caseload. We assume that to meet contractual
obligations, our hypothetical TC must on average admit 15 arthroscopy cases
and 15 knee replacement cases per week. We assume that weekend
admissions are not permitted.
As a base line case, we assume that three arthroscopy patients and three
knee replacement patients are admitted on each weekday. This is compared
to an optimal cyclic admissions schedule that smoothes out the weekly
variation in bed demand, although other performance criteria may be
preferred.
With the baseline case where admissions are distributed uniformly, the
minimum reserve capacity of 11.8 per cent occurs on Fridays, here the upper
95th percentile for bed demand is 32.9, exceeding the 32 beds available. On
the other hand, if the optimal pattern of weekly admissions (Table 5) were
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adopted, then there would be less pressure on beds. The provision of 32 beds
is adequate to ensure reserve capacity of at least 21.9 per cent throughout
the week (see Figure 12), and the maximum 95th percentile has reduced by
7.9 per cent from 32.9 to 30.3 beds (see Figure 13).
Table 5 The optimum admissions pattern derived by integer programming
maximising the minimum reserve capacity during the week (the minimum
reserve capacity during the week is shown in italics)
Daily admissions by health care resource group
Weekday Arthroscopy Primary knee
Reserve Capacity (%)
Mean bed demand
95th percentile for bed demand
Monday 7 0 22.43 26.14 29.75
Tuesday 5 0 21.91 26.25 30.25
Wednesday 3 4 23.76 25.86 29.92
Thursday 0 6 25.95 25.41 29.49
Friday 0 5 22.08 26.21 30.32
Saturday 0 0 36.52 23.44 27.52
Sunday 0 0 51.34 21.14 25.05
Figure 12 Variation in reserve capacity during week comparing the baseline
(homogeneous) admission pattern with the optimised admission pattern.
0
10
20
30
40
50
60
70
M T W Th F S S
Weekday
Reserve Cappacity (%)
Homogeneous
Optimised
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Figure 13 The 95th upper centile for number of beds required during days of
week comparing the baseline (homogeneous) admission pattern with the
optimised admission pattern
This simple hypothetical example points to the possibility of using such
modelling as the basis for intelligent scheduling of admissions from different
health related groups where there are systematic differences in length of
stay. This has the potential for giving operational advantages by smoothing
out bed demand throughout the planning cycle, reducing capacity needs or
making better use of existing capacity. Importantly, such efficiency gains
would cost little or nothing other than the costs of implementing a new
protocol for booking admissions.
8.4 Potential extension of modelling to the case of multiple hospital environments
The analysis methods discussed in the previous sections can be extended to
assist with another important problem: hospital planning related to the
identification of bottlenecks within the system. Here the issues go beyond the
operation of a single ward or unit and concern the progression of patients
through a succession of care processes within a hospital, each taking place
within distinct locations. An example of this is cardiothoracic surgery where
patients move from ward to operating room to a recovery room, or possibly
an intensive care environment, then back to a ward prior to discharge (see
Figure 14).
0
5
10
15
20
25
30
35
M T W Th F S S
95th centile for bed demand
Homogeneous
Optimised
Weekday
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Figure 14 Representation of the patient journey through successive clinical
environments during the course of their treatment
Here, given sufficient data, one can in principle typify a patient’s journey
through the care process in terms of location/probability distributions as
illustrated in Figure 15.
In a manner similar to that used to derive the expressions discussed in the
previous section, analytical expressions can be obtained for the mean and
variance of the ‘bed demand’ in different hospital locations.
The exact form of these is complex and again, to the layman no doubt appear
to be ‘algebraic alphabet soup’, however the importance of these is that they
again give a means of applying powerful optimisation methods. In this
extended context, these would enable one not only to establish optimal
booking patterns, but also to establish where the system bottlenecks are and
the potential effects of investing in new resources within the system.
Figure 15 Location probabilities for a patient dependent on time since
admission
’
’
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Developing and testing of such analytical methods for admissions and
resource planning is an exciting new research direction that has been
identified as a result of the current SDO project; however full development
and testing of the ideas goes beyond the remit of the project plan.
Fortunately, there is the opportunity to try out some of the ideas in the
context of a study funded by Great Ormond Street hospital. Also, some of
these modelling methods may form the foundation for another operational
research project funded by SDO related to restructuring services for common
mental health problems.
8.5 Modelling outpatient requirements
The final section related to modelling that may assist the operation and
planning of TCs concerns the operation of outpatient clinics. The problems
examined are actually more general and could in principle be applied in the
context of any hospital, but they are particularly appropriate to the planning
of new TCs where the planner may have to make decisions from scratch
about issues such as the number of examination rooms required, the number
of clinic sessions and how they will be assigned to rooms depending on the
availability of appropriate clinical staff and the expected patient demand for
the different specialties catered for within the TC. This is somewhat different
from the situation where outpatient plans have evolved piecemeal over many
decades.
While the operation of outpatient services does not have to deal with the
complexities of length of stay variability (although there is still some
variability in the time that an examination takes), there are still difficulties
faced by the planner in terms of a need to develop clinic schedules and room
allocations that meet a number of different requirements. Some of the key
issues that must be catered for are illustrated in Figure 16.
Figure 16 Elements contributing to modelling of outpatient scheduling and
room allocation
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The problem has some elements that entail fixed constraints (for example
some clinic types require a room equipped with specialist equipment) while
others represented somewhat softer constraints (for example Sir Lancelot
Spratt prefers to work elsewhere on a Friday afternoon).
The organisation of outpatient clinics is another aspect of health care systems
that has previously been explored by operational researchers (see for
example Jackson et al, 1964; Vissers and Wijndgaard, 1979). The
mathematical difficulty of finding a reasonable clinic plan is easy to
underestimate. For example, could one not just compute all possible
schedules and see which is best?
In the context of a typical London teaching hospital, which is admittedly
larger than many TCs, assuming a planning cycle of one week, each with 10
sessions, there would be of the order of two to the power of 285 (2285)
different potential schedules. This is a number bigger than the number of
atoms in the universe. Even with modern day computers, evaluation of each
possibility separately would take longer than the age of the universe.
Research was carried out to examine the scope for applying optimisation
techniques to help to resolve this problem. Initial investigation soon identified
a way in which a technique called integer programming formulation (Williams
1993) could be used. However, this was complex and would thus require
large scale computing requirements and specialist software which hospitals
and TCs would be unlikely to have the expertise to use or the wish to buy.
Further analysis produced a modified version of the problem, greatly reducing
its complexity. In addition, the new formulation expressed the problem in a
form that has a special mathematical symmetry. Unexpectedly, this enabled
pure mathematical techniques to be applied, and it was established that a
simple optimisation method known as linear programming could be used to
solve the planning problem. The consequence of this is that, even for
relatively large scale outpatient departments, planning software to assist
clinic scheduling and capacity planning could be developed using relatively
modest computing facilities. For example, a prototype software tool was
developed making use of the Excel spreadsheet package, which is known well
by many hospital planners.
A bizarre post script to this research on outpatient scheduling was the
realisation that the analysis methods developed could be used to prove a
generalisation of a famous theorem in pure mathematics known as the
Birkhoff-Von Neumann theorem (Birkhoff, 1946; Von Neumann, 1953).
In itself, this does nothing to further the cause of health care management,
although perhaps it does serve to underline the mathematical pedigree of the
research.
Again, this research has opened up promising new topics for future study,
although resources were not available within the current grant to investigate
them further, since to do so would have distracted from the remit of the
proposal.
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8.6 Summary
This section has described the use of mathematical modelling in the context
of TC operation and planning particularly in relation to issues of capacity
requirements. Due to fortunate mathematical discoveries, research has gone
much further than originally envisaged.
While the development of specific software tools has been beyond the remit
and resources of the research, a number of models have been developed that
have the potential for further development to assist with operational planning
both of TC and non-TC health environments. These include:
• a stochastic model for forecasting weekly fluctuations in bed demand and
its variance depending on rates of emergency admission, length of stay
variation, ‘do not attend’ (DNA) rates, case mix and the admissions
booking pattern
• optimisation methods for maximising reserve capacity by judicious choice
of the pattern of booked admissions
• an optimisation framework for the analysis of admissions that have
several treatment phases taking place in different parts of a hospital.
Such modelling can assist both admissions planning, the identification of
system bottlenecks and resource allocation
• mathematical methods to assist with the design and scheduling of
outpatient facilities.
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Section 9 Treatment centres and the efficient use of capacity
In Section 8 we highlighted the important role of variability in determining
capacity requirements for a hospital unit. In line with the intention stated in
the original proposal, in this section we explore this notion in greater detail,
drawing a distinction between the amount of variability in a system and the
impact of that variability on capacity requirements. We then describe how the
mathematical models of capacity requirements discussed in Section 8 have
been used to assess capacity requirements in a large number of hypothetical
scenarios with a view to identifying circumstances in which the introduction of
a treatment centre to a local health economy is an efficient use of additional
capacity.
The focus of this section is very much on the structure of inpatient services
available within a local health economy rather than on how individual
treatment centres or other hospital units organise the delivery of care. With
this in mind, and solely for the purpose of the analysis presented in this
section, we view a treatment centre as a pool of capacity that differs from
other hospital units only in the categories of patient that are referred to it.
The technical detail of the work that has been done would, in our view, be
unpalatable to a general audience, so we present here an overview of this
mathematical work in terms that are hopefully comprehensible.
We begin with an explanation of the mathematical concepts that underpin
this work and the calculations that have been performed before giving an
account of how we collated the data used in these calculations. The results of
the modelling work are then presented and discussed.
9.1 One argument for introducing a treatment centre: managing variability
The folly of estimating capacity requirements based on the average demand
for beds is established in Section 8. Even if the number of admissions on any
given day is known with certainty, any variability in length of stay leads to
there being variability in the number of beds required each day. The amount
of variability in a quantity such as bed demand or length of stay is measured
in statistical terms using the so-called variance; the higher the variance, the
greater the variability.
The illustrative example given in Figure 17 shows that, if one wants to meet
demand on 95 per cent of days, different levels of variability result in
different capacity requirements, even though the average demand for beds is
the same.
While some patient-to-patient variability in length of stay is inevitable due to
intrinsic differences in the needs of patients and the response of patients to
treatment, it is often possible to identify factors that are associated with
shorter or longer stays in hospital. Such factors might include whether the
patient is an emergency admission, the procedure to be administered, the
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age and fitness of the patient and any co-morbidities that the patient has
such as diabetes.
The identification of such factors offers the opportunity to separate patients
likely to have a long length of stay from those likely to have a short length of
stay. Using different pools of capacity for patient groups defined in this way
could in principle lead to a reduction in variability. Consider the length of stay
distribution shown in Figure 18. Splitting this into two separate distributions
can give a lower total variance. Hence, one argument for the introduction of a
treatment centre is that, by separating shorter stay patients from longer stay
patients, it is possible to reduce the amount of variability in the system.
Figure 17 An illustration of the importance of variability in determining capacity
requirements
0 5 10 15 20 25 30
0 5 10 15 20 25 30
0 5 10 15 20 25 30
Average demand...15 beds
(Variance...............20)
Capacity required to
meet demand 95%
of the time..............22 beds
Average demand...15 beds
(Variance...............10)
Capacity required to
meet demand 95%
of the time..............20 beds
Average demand...15 beds
(Variance.................5)
Capacity required to
meet demand 95%
of the time..............19 beds
Demand
Demand
Demand
Frequency
Frequency
Frequency
0 5 10 15 20 25 30
0 5 10 15 20 25 30
0 5 10 15 20 25 30
Average demand...15 beds
(Variance...............20)
Capacity required to
meet demand 95%
of the time..............22 beds
Average demand...15 beds
(Variance...............10)
Capacity required to
meet demand 95%
of the time..............20 beds
Average demand...15 beds
(Variance.................5)
Capacity required to
meet demand 95%
of the time..............19 beds
Demand
Demand
Demand
Frequency
Frequency
Frequency
0 5 10 15 20 25 30
0 5 10 15 20 25 30
Average demand...15 beds
(Variance...............20)
Capacity required to
meet demand 95%
of the time..............22 beds
Average demand...15 beds
(Variance...............10)
Capacity required to
meet demand 95%
of the time..............20 beds
Average demand...15 beds
(Variance.................5)
Capacity required to
meet demand 95%
of the time..............19 beds
Demand
Demand
Demand
Frequency
Frequency
Frequency
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Figure 18 An illustration of how identifying patients likely to have a shorter
stay could lead to a reduction in unpredictable variability
9.2 One argument for not introducing a treatment centre
In Section 8 it was explained that for a hospital unit to operate effectively in
the presence of variability it requires more beds to be available than will be
occupied on average. The number of beds required to avoid frequent
operational emergencies is dependent on two factors. As outlined in the
previous section, the degree of variability in the system is a key determinant
of the level of capacity required. However, the overall scale of the system
considered is also important factor.
0 5 10 15 20 25 30
Variance = 20.0
0 5 10 15 20 25 30
5 10 15 20 25 30
Variance = 6.5
Variance = 7.8
Separating shorter stay
patients from longer stay
patients reduces the
variability in the system
Length of stay
Length of stay
Length of stay
Frequency
Frequency
Frequency0 5 10 15 20 25 30
Variance = 20.0
0 5 10 15 20 25 30
5 10 15 20 25 30
Variance = 6.5
Variance = 7.8
Separating shorter stay
patients from longer stay
patients reduces the
variability in the system
Length of stay
Length of stay
Length of stay
Frequency
Frequency
Frequency
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The illustration shown in Figure 19 shows that, other things being equal,
capacity requirements are less if a single pool of capacity is used. In this
illustration, the total variability in demand is the same whether one or two
pools of capacity are provided, however the impact of this variability is less if
a single pool of capacity is used. In this sense, there are economies of scale
in hospital capacity planning. Hence, one argument against the introduction
of a treatment centre is that having separate pools of capacity for different
groups of patients might increase the impact on overall capacity requirements
associated with whatever variability there is in the system.
Figure 19 An illustration of why, in some circumstances, it is better to have one
large unit of capacity rather than two smaller ones
For a given average
demand and total
variability, a single
pool of capacity is
more efficient.
Demand
Frequency
Frequency
Average demand...15 beds
(Variance...............10)
Capacity required to
meet demand 95%
of the time..............20 beds
Demand
FrequencyDemand
Average demand...30 beds
(Variance...............20)
Capacity required to
meet demand 95%
of the time..............37 beds
Average demand...15 beds
(Variance...............10)
Capacity required to
meet demand 95%
of the time..............20 beds
For a given average
demand and total
variability, a single
pool of capacity is
more efficient.
Demand
Frequency
Frequency
Average demand...15 beds
(Variance...............10)
Capacity required to
meet demand 95%
of the time..............20 beds
Demand
FrequencyDemand
Average demand...30 beds
(Variance...............20)
Capacity required to
meet demand 95%
of the time..............37 beds
Average demand...15 beds
(Variance...............10)
Capacity required to
meet demand 95%
of the time..............20 beds
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9.3 Comparing capacity requirements with and without a treatment centre
There is seemingly a tension between the two arguments presented above.
On the one hand, the introduction of a treatment centres offers the
opportunity to reduce the total variability in demand for beds by using
separate pools of capacity for groups of patient that differ in terms of their
length of stay characteristics; on the other hand having separate pools of
capacity runs contrary to the economies of scale in capacity planning and may
increase the impact of variability in demand on capacity requirements of
variability in demand.
To explore the interplay between these two effects, we have adapted one of
the models of capacity requirements introduced in the previous section. This
has been done by constructing a large number of hypothetical scenarios. For
each scenario we have estimated the capacity required to meet demand 95
per cent of the time in all units (TC or non-TC) for two distinct configurations
of inpatient services: one in which there is no separation of shorter stay
patients from longer stay patients and one in which shorter stay patients are
referred to a treatment centre. An illustration of one such scenario is given in
Figure 20.
To give one measure of the relative efficiency of the two service
configurations we then calculate ρ, the ratio of the capacity requirements with
a treatment centre to the capacity requirements without a treatment centre
(see Figure 21). If ρ is equal to 1, the implication is that capacity
requirements are the same regardless of whether a TC is introduced to a local
health economy or not. A value of ρ less than one suggests that the
introduction of a TC would lead to a more efficient use of capacity across a
local heath economy as a whole; a value greater than one suggests that the
introduction of a TC would lead to a less efficient use of capacity across the
local heath economy.
Figure 20 Two configurations of inpatient services within a local health
economy, in one of which a treatment centre delivers services to those patients
identified as likely to have a shorter hospital stay
Hospital 1
Hospital 1
TC
Hospital 2
Hospital 2
Hospital 1Hospital 1
Hospital 1Hospital 1
TCTC
Hospital 2Hospital 2
Hospital 2Hospital 2
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Figure 21 The modelling work has involved comparing the capacity
requirements associated with two configurations of inpatient services (with or
without a treatment centre) in a large number of hypothetical scenarios
In taking the workload as fixed and determining which of two configurations
of service is the most efficient for dealing with this throughput, there is an
implicit assumption that greater throughput could be achieved with the more
efficient configuration.
9.3.1 The importance of taking a ‘whole system’ view
It is important to note at this stage that our focus is on the impact of a TC on
the efficient use of capacity within the system as a whole. Given the
characteristics of the patients referred to a TC, it is likely that greater
efficiency in the use of capacity can be achieved within a TC environment
than in a non-TC environment. However, it is entirely possible that a TC could
be extremely efficient in terms of capacity use and yet have a detrimental
effect on the efficient use of capacity within the local health economy that it
serves as a whole.
9.4 Modelling the intelligent selection of patients for referral to a treatment centre
One defining characteristic of the scenarios that have been evaluated is the
extent to which the patient population can be separated into longer-stay
patients and shorter-stay patients, with the shorter-stay patients deemed
suitable for referral to a treatment centre. Whereas the number of admissions
per day, for example, is a simple concept, there is no simple way of
characterising the degree of success in such ‘intelligent’ selection of patients.
For now, we discuss different ways of separating the overall patient
population into two groups of equal size. In the worst case, the patient
population identified as likely to have shorter stays (and referred to a
treatment centre) would in fact have exactly the same length of stay
characteristics as those patients identified as likely to have longer stays
(Figure 22a). The best possible selection of patients would result in every
patient identified as likely to have a shorter stay actually having a shorter
hospital stay than every patient in the group identified as likely to have a
longer stay (Figure 22b).
ρ =
Capacity requirements of
Hospital 1 Hospital 2
Capacity requirements of
TCHospital 1 Hospital 2
ρ =
Capacity requirements of
Hospital 1 Hospital 2Hospital 1Hospital 1 Hospital 2Hospital 2
Capacity requirements of
TCHospital 1 Hospital 2TCTCHospital 1Hospital 1 Hospital 2Hospital 2
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Figure 22 The two extreme cases in which identifying patients likely to have a
shorter stay is (A) entirely unsuccessful or (B) entirely successful
(A) Worst case
(B) Best case
In reality, the success achieved in identifying shorter-stay patients for referral
to a TC is likely to fall between these two extremes. To define the different
hypothetical scenarios that have been evaluated as part of this project, we
Cost of stay
Frequency
Cost of stay
Frequency
Cost of stay)
Frequency
Refer to TC
Refer to hospital
Cost of stay
Frequency
Cost of stay
Frequency
Cost of stay
Frequency
Cost of stay)
Frequency
Cost of stay)
Frequency
Refer to TC
Refer to hospital
Length of stay (days)
Frequency
Length of stay (days)
Frequency
Length of stay (days)
Frequency
Refer to TC
Refer to hospital
Length of stay (days)
Frequency
Length of stay (days)
Frequency
Length of stay (days)
Frequency
Length of stay (days)
Frequency
Length of stay (days)
Frequency
Refer to TC
Refer to hospital
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used a mathematical function that has a parameter α, different values of
which represented different degrees of success in identifying shorter-stay
patients. The illustration shown in Figure 23 shows, for a hypothetical length
of stay distribution, the separation between short-stay patients and longer-
stay patients represented by α = 3.
Figure 23 Modelling patient selection. An illustration of how we modelled the
degree of success achieved in separating shorter stay patients from longer stay
patients
9.4.1 The interplay between economies of scale and
patient selection
In this section we illustrate the analysis that has been performed in the
context of the simplest set of scenarios that were constructed, in which there
is just one non-TC hospital site. Example results for such a set of scenarios
are shown in Figure 24. Each tile in this chart represents an estimate of the
impact of introducing a TC on capacity requirements for a given combination
of the scale of the non-TC hospital (the number of daily admissions in the
absence of a treatment centre) and ρ, the degree of success in identifying
patients likely to have a shorter stay. The colour of each tile indicates the
value of α where, as stated previously, a value of ρ less than one indicates
that a TC would have a positive impact on the efficient use of capacity within
the local health economy.
Modelling patient selection
Refer to TC
Refer to hospital
Length of stay
We used a parameterised
mathematical function to represent the
degree to which intelligent selection of
patients can be achieved.
Frequency
Length of stay
% referred to hospital
50%
100%
Refer to TC
Refer to hospital
Length of stay
We used a parameterised
mathematical function to represent the
degree to which intelligent selection of
patients can be achieved.
Frequency
Length of stay
% referred to hospital
50%
100%
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Figure 24 Example results showing the impact of introducing a treatment
centre on the efficiency with which capacity is used in a large number of
hypothetical scenarios
It is apparent from these example results that, in this set of scenarios, there
is a trade-off between the reduction in variance achieved with patient
selection and the economies of scale. Moving from left to right across Figure
24, the greater the degree of success in identifying patients likely to have a
shorter stay (α), the more beneficial the impact of a TC. However, for a given
value of α, the higher the number of daily admissions the less beneficial
introduction of a TC. Note that the nature of the interplay between the
number of daily elective admissions and α is specific to the length of stay
distribution of the patient population considered. This is discussed in more
detail later in this section.
9.5 Other factors that may influence the relative efficiency of different service configurations
In addition to the effects of the intelligent selection of patients and the
economies of scale discussed in Section 9.4.1, there are a number of other
factors that may influence whether or not the introduction of a TC has a
beneficial impact on the efficient use of capacity within a local health
economy. The other factors that have been used to define the scenarios
evaluated in this study are given below.
Level of emergency admissions as a proportion of elective admissions
As the introduction of a TC is intended to separate routine elective services
from more complex elective and emergency work, the level of emergency
admissions among the patient population concerned is clearly an important
Worseρ > 1
Marginally better0.975 < ρ = 1
Better0.95 < ρ = 0.975
Much betterρ < 0.95
αααα (degree of success in identifying shorter stay patients)
N (number of daily admissions)
2
10
4
6
8
12
14
16
18
20
1 3 5 9 11 13 15 17 19 21 23
Efficiency of capacity use
if a TC is introduced
Worseρ > 1
Marginally better0.975 < ρ = 1
Better0.95 < ρ = 0.975
Much betterρ < 0.95
αααα (degree of success in identifying shorter stay patients)
N (number of daily admissions)
2
10
4
6
8
12
14
16
18
20
1 3 5 9 11 13 15 17 19 21 231 3 5 9 11 13 15 17 19 21 23
Efficiency of capacity use
if a TC is introduced
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consideration. In addition to increasing average demand, emergency
admissions increase the amount of unpredictable variability in the system. It
is likely then, that for the same level of elective admissions, the interplay
between patient selection and economies of scale will have different
characteristics dependent on the level of emergency admissions. In the
scenarios that have been evaluated, the average rate of emergency
admissions was taken to be a given percentage of the daily rate of elective
admissions (zero, 10 or 20 per cent).
Number of non-TC hospitals within the catchment area of a single TC
The example results shown at Figure 24 are for the simplest set of scenarios
where, if introduced, a TC would only accept referrals that would otherwise be
made to a single non-TC hospital. However, in some local health economies, a
TC might accept patients that would otherwise have attended one of a
number of non-TC hospitals, potentially increasing the average demand at the
TC and affecting the interplay between economies of scale and patient
selection. Scenarios were evaluated where, if introduced, a TC would provide
services to a catchment area shared by one, three or five non-TC hospitals.
For the sake of simplicity, within each scenario all non-TC hospitals were
considered to be identical.
Length of stay distribution for patient population
From Figure 24, it is clear that the impact of introducing a TC depends on the
degree of success achieved in identifying patients likely to have a shorter
stay. Another potentially important factor is the overall distribution of length
of stay among the patient population considered, as this influences average
demand and the total variability in demand in the absence of any intelligent
selection of patients. We evaluated scenarios in which the patient population
concerned had the length of stay characteristics of urological surgery
patients, general surgery patients and orthopaedic surgery patients.
Overall proportion of patients that would be referred to the TC
The results shown at Figure 24 are for a set of scenarios in which half of all
the elective patients within the patient population concerned (the half
identified as likely to have shorter length of stay) are referred to the TC.
Changing this proportion changes both the number of patients referred to
each setting and the length of stay characteristics of patients referred to each
setting. We evaluated sets of scenarios where one quarter, one half or three
quarters of all elective patients were referred to the TC.
9.6 Data collation
As mentioned in the previous section, one of the defining characteristics of
each scenario that was constructed as part of the modelling work was the
length of stay distribution for the patient population concerned. In this section
we present the different length of stay distributions that were used in our
calculations.
We obtained data concerning all admissions to hospital trusts in England for
the years 2001/2, 2002/3 and 2003/4 from Hospital Episode Statistics
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(Department of Health, 2005e). This dataset contained information about the
patient’s admission method (such as elective or emergency), specialty (in
terms of health care resource group), admission date and discharge date. We
then extracted all urology, orthopaedic and general surgery patients from the
dataset. Table 6 indicates the number of patient entries that were extracted:
Table 6 Number of patient entries extracted from the Hospital Episode Statistics
data, for patients in urology, orthopaedic or general surgery specialties
Number of entries Data set Date range
Total Extracted
2001/2 April 2001 – March 2002 12,973,256 2,205,349
2002/3 April 2002 – March 2003 13,442,308 3,477,514
2003/4 April 2003 – March 2004 14,133,974 3,957,997
Table 7 shows the proportion of records which had incomplete length of stay
information and which therefore could not be used within our analysis.
Patients that stayed in hospital for less than one day were assumed to be day
cases rather than inpatients and these records were not used in our analysis
of capacity requirements for inpatient services. The length of stay distribution
for elective inpatients was constructed for each specialty for each of the three
years using a log-linear scale (not shown). On inspection of these graphs, we
considered that it was reasonable to take the 2002/3 data set as
representative of the length of stay distribution for the entire three year
period.
Table 7 Proportion of day case patients, patients staying at least one day and
patients with incomplete length of stay information in each year and specialty
category
Length of stay (days)
Specialty
Year
Number Not available / Incomplete 0 1 or more
2001/2 81,316 0.61% 80.19% 19.19%
2002/3 406,376 3.51% 76.12% 20.37%
Urology
2003/4 366,924 3.59% 76.78% 19.63%
2001/2 36,142 0.91% 37.39% 61.70%
2002/3 217,385 7.05% 38.12% 54.84%
Orthopaedics
2003/4 192,786 6.90% 37.12% 55.98%
2001/2 94,116 2.17% 63.20% 34.63%
2002/3 428,385 10.49% 58.13% 31.38%
General surgery
2003/4 316,078 10.26% 56.88% 32.86%
Length of stay scenarios: elective admissions
In the hypothetical scenarios that were constructed, three length of stay
distributions were used. For each of these distributions, in order to limit the
tail of the distribution, patients staying for more than 128 days were assumed
to stay exactly 128 days. Figures 25, 26 and 27 show the distributions used
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to represent the length of stay characteristics of elective urology, orthopaedic
and general surgery patients.
Figure 25 Distribution of length of stay for elective urology patients that stayed
at least one night in hospital
Figure 26 Distribution of length of stay for elective orthopaedic surgery
patients that stayed at least one night in hospital
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0 10 20 30 40 50 60 70 80 90 100 110 120
Length of stay (days)
Probability
0
0.05
0.1
0.15
0.2
0.25
0 10 20 30 40 50 60 70 80 90 100 110 120
Length of stay (days)
Probability
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Figure 27 Distribution of length of stay for elective general surgery patients
who stayed at least one night in hospital
Source for Figures 25, 26 and 27: Hospital Episode Statistics 2002/3
Length of stay for emergency admissions
From the 2002/3 returns to HES, we also extracted separate length of stay
distributions for emergency and transfer patients for each specialty. These
distributions are shown in Figures 28, 29 and 30.
Figure 28 Distribution of length of stay for urology patients admitted as an
emergency that stayed at least one night in hospital
0.00
0.02
0.04
0.06
0.08
0.10
0.12
0.14
0 10 20 30 40 50 60 70 80 90 100 110 120
Length of stay (days)
Probability
0
0.05
0.1
0.15
0.2
0.25
0 10 20 30 40 50 60 70 80 90 100 110 120
Length of stay (days)
Probability
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Figure 29 Distribution of length of stay for orthopaedic surgery patients
admitted as an emergency that stayed at least one night in hospital
Figure 30 Distribution of length of stay for general surgery patients admitted as
an emergency that stayed at least one night in hospital
0
0.05
0.1
0.15
0.2
0.25
0 10 20 30 40 50 60 70 80 90 100 110 120
Length of stay (days)
Probability
0
0.05
0.1
0.15
0.2
0.25
0 10 20 30 40 50 60 70 80 90 100 110 120
Length of stay (days)
Probability
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9.7 Results
With three patient populations, three different values for the proportion of
elective patients referred to the TC, three different values for the number of
non-TC hospitals and three different levels of emergency admissions, 81
(3x3x3x3) sets of scenarios such as that shown in Figure 24 were evaluated;
this corresponds to a total of approximately 880 distinct scenarios. Clearly the
space available here prohibits us from presenting the results of every
scenario. We present here results for a selection of 18 sets of scenarios.
Figure 31 shows results for nine sets of scenarios concerning the introduction
of a TC to deliver urological surgery services.
Figure 31 The impact of the introduction of a treatment centre on the efficient
use of capacity for a large number of hypothetical scenarios related to the
delivery of inpatient urology services
In all of these scenarios, half of all elective urological surgery patients are
referred to the TC. Each small chart within Figure 31 is analogous to Figure
24, showing the impact of a TC on capacity requirements depending on N (the
number of daily booked elective admissions to each non-TC site if no TC is
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introduced) and α (the degree of success achieved in intelligent patient
selection). The top row of three charts relates to scenarios in which the TC is
introduced to a local health economy with just one non-TC hospital, with the
level of emergency admissions increasing from 0 per cent (leftmost chart) to
20 per cent (rightmost chart). The middle row relates to scenarios in which
the TC is introduced to a local health economy with three non-TC hospitals.
The results in the bottom row relate to scenarios in which there are five non-
TC hospitals. Figure 32 shows results for the equivalent scenarios concerning
the introduction of a TC to deliver orthopaedic surgical services.
Figure 32 The impact of the introduction of a treatment centre on the efficient
use of capacity for a large number of hypothetical scenarios related to the
delivery of inpatient orthopaedic services
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9.8 Discussion
These figures display a number of interesting features. Firstly it can be seen
that, the higher the level of emergency admissions, the less beneficial the
impact of a TC on the capacity requirements for the local health economy as a
whole. Secondly, a key finding is that the more non-TC hospitals that refer
patients to a TC, the more beneficial the impact of a TC on capacity
requirements. Put simply, this has the effect of increasing average demand at
the TC and economies of scale at the TC counter the deleterious effect of
having an extra unit of capacity. These two effects are seen for general
surgery patients also (results not shown).
Another finding of interest is that the interplay between the daily number of
elective admissions to each non-TC in the absence of a treatment centre and
patient selection is more complicated than a simple trade-off and depends on
the length of stay distribution for the patient group concerned. This is for two
reasons: the mean length of stay influences the average demand for beds
within the system and hence the impact of variability; the length of stay
distribution determines the reduction of variability associated with a particular
value of α. That said, it is generally the case that the introduction of a TC had
a more beneficial impact in scenarios where greater success is achieved in
identifying shorter stay patients.
The scenarios in which the introduction of a TC seems to offer most
theoretical benefits are those in which the TC serves a catchment area where
there are a large number of non-TC hospitals, where there is considerable
success in identifying and referring to the TC patients that are likely to have a
shorter length of stay and for which there is little emergency demand among
the relevant patient population as a whole. (Such scenarios are represented
by the right hand side of the bottom left ‘tiles’ in Figures 31 and 32.)
9.8.1 Aside: what if the treatment centre admitted the
longer stay patients?
One of the great advantages of mathematical modelling as a research tool is
that one can explore extreme or perhaps infeasible scenarios to see whether
the results provide insight into the key dynamics of the system. To this end,
we constructed additional scenarios in which, rather than admit patients
requiring routine elective procedures, the TC took those elective patients
identified as likely to have longer stays; in these scenarios the non-TC
hospitals admitted emergency patients and those identified as likely to have
shorter length of stay. The results for orthopaedic surgery patients are shown
in Figure 33. It can be seen that, from the narrow perspective considered
within in this modelling work, the impact of introducing a TC is particularly
beneficial in some of these scenarios, particularly those in which there is
more than one non-TC hospital. This is because there would be greater
economies of scale in pooling those patients that show longer (and typically
more variable) length of stay. While clearly at odds with the ethos of TCs,
from the point of view of making the most efficient use of capacity, it would
make better sense to centralise the delivery of services for patients likely to
have a longer stay in hospital. This is not a new notion (see for example
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Bowers and Mould, 2002), indeed similar thinking underpinned the creation of
sanatoria for tuberculosis in the last century.
Figure 33 The impact of the introduction of a treatment centre on the efficient
use of capacity for inpatient orthopaedic services
Note: In these scenarios, long stay patients are referred to the TC while short stay and
emergency patients remain in the non-TC hospitals
9.8.2 Caveats
It is important to note that the mathematical modelling that has been
conducted was intentionally limited in scope and a number of caveats should
be borne in mind when interpreting the results presented here.
The mathematical modelling aspect of this study was intended to inform a
theoretical evaluation of TCs as a mode of service delivery from a narrow
perspective concerning the impact of the structural changes to service
delivery within a local health economy associated with the introduction of a
TC on the efficient use of capacity within the whole system. There is an
implicit assumption in our work that increasing capacity available within the
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local non-TC hospitals is a viable alternative to increasing capacity via the
introduction of a TC. In some urban areas this may not be the case.
The scenarios constructed differed only in the structure and organisation of
service delivery. Figure 34 illustrates the mechanisms by which TCs could
potentially improve the efficient use of capacity within a local health
economy. The modelling work presented in this section has covered two of
the five potential mechanisms identified. The potential for the intelligent
scheduling of elective admissions is discussed in Section 8. Importantly, no
account was taken of the possibility that a given patient would stay in
hospital for a shorter period of time if treated within a TC than in a non-TC
environment. Genuine reduction in length of stay within TCs (as opposed to
apparent reduction in length of stay due to patient selection) would clearly
improve the prospects of a TC in improving the efficient use of capacity.
Although beyond the scope of the current project, the methods used in this
research could be extended to evaluate scenarios that incorporate this
possibility.
Another feature of hospital operation not considered within this work is that
of theatre utilisation. The work of Mould et al (2002) suggests that separating
routine elective work from more complex elective work and emergency
services is likely to have a detrimental effect on theatre utilisation within the
non-TC sites.
Figure 34 Mechanisms by which the introduction of TCs might improve the
efficient use of capacity
9.9 Summary
The construction and evaluation of a large number of hypothetical scenarios
has enabled us to identify circumstances in which the introduction of a TC
might improve the efficiency with which capacity is utilised within a local
health economy. The circumstances under which the introduction of a TC does
seem to offer such theoretical benefits are those where the TC serves a
catchment area where there are a large number of non-TC hospitals and
where there is considerable success in identifying and referring to the TC
patients that are likely to have a shorter length of stay.
Intelligent Scheduling of
Elective Admissions
Intelligent Selection of
Patients for TCs
Economies of ScaleGains in efficiency for
whole system?
Structure and
organisation of service
Reducing Length of Stay
Reducing Variability in Length of Stay
Management
of patients
Intelligent Scheduling of
Elective Admissions
Intelligent Selection of
Patients for TCs
Economies of ScaleGains in efficiency for
whole system?
Structure and
organisation of service
Reducing Length of Stay
Reducing Variability in Length of Stay
Management
of patients
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Another finding of this work is that, in the absence of genuine length of stay
reduction within TC environments, there are circumstances in which the
introduction of a TC may have a negative impact on the efficient use of
capacity within the local health economy as a whole. These circumstances
include the delivery of services where the proportion of all admissions that
are emergency cases is significant and in which, for whatever reason, it is not
possible to identify, at the point of referral, patients likely to have a shorter
length of stay.
It is of interest that, from the perspective of improving efficiency in capacity
use across a local health economy as a whole, the key determinant of success
seems to be a number of non-TC trusts co-operating with primary care to
ensure that, for a given procedure, patients identified as likely to have a
shorter length of stay are referred to the TC while they admit a much more
challenging case load. Whether such co-operation is likely given the
competitive environment that hospitals find themselves operating in is
questionable.
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Section 10 Conclusions and discussion of the implications for policy, concepts, practice and research
Our three-year research study examining TCs as organisational innovations in
the NHS set out to achieve two broad objectives:
1 to conduct a technical evaluation (incorporating mathematical modelling)
both of the concept and actual impact of TCs as an innovative way of
delivering health care within the NHS
2 to study – using qualitative methods – the organisational and social
factors associated with the development of TCs in order to demonstrate
how these impact upon the implementation process and its
organisational outcome.
Having presented our detailed findings in Sections 3 to 9, we conclude with a
brief summary of our main findings, followed by a discussion of the
implications of our research for future policy, practice, and research with
regard to organisational innovation and service development in the NHS.
10.1 Conclusions
When the NHS Plan was launched in 2000, TCs were a promising
organisational innovation based on practice exemplars, rather than research
evidence; but their political time had come. By 2003, as our study
commenced, it was clear that strong political and organisational drivers were
spearheading their rapid diffusion into the NHS. But the innovation was part
of a much wider government drive to modernise the NHS. Accordingly the TCs
were launched into the dynamic and complex organisational milieu of an NHS
in transformation – a milieu in which multiple parallel changes, all likely to
impact on the fledgling TCs, were occurring with great speed. These included
a programme of independent (private) sector TCs as part of a wider
governmental push towards involvement of the private sector in the delivery
of care, presaged in the NHS Plan; the introduction of Payment by Results, a
new system for reimbursement; and the simultaneous introduction of the
Patient Choice initiative and the Choose and Book programme. As a result,
our study became the story not of a single innovation and its impact on
health services, but the organisational response of one emerging sector of
care in a maelstrom of modernisation.
Despite this welter of modernising initiatives, the central programme for
developing TCs gave an opportunity for local developments to take place that
– while they often differed greatly from the ideal TC as envisaged by the
Department of Health and the Government - contained many of the intended
principles. Thus the central programme allowed, as it were, headroom for
local managers to implement their own desired innovations. While the
Department of Health might not always be able to make things happen as
they would have liked, the central programme had the effect of letting things
happen locally that might otherwise not have occurred. The centre also
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created structures intended to help the local innovators – not only directly
with such initiatives as the Modernisation Agency’s learning events and advice
(including some elementary design rules for this particular type of
organisational innovation), but also by providing capital funding, a direct
stimulus with associated performance expectations.
The cultures of our eight sample sites that chose to open TCs were all very
different from each other. We found a range of management styles,
aspirations, relationships and pressures. However, the one factor which
united them was the sense that this particular organisational change was
timely and necessary, and alongside this we found a ‘can do’ mentality and
the presence of some core ‘champions’ who were keen to implement this
innovation. The nascent TCs’ relationships with their external milieu – the
local health economy including the host trust, the PCT, the SHA, neighbouring
trusts, and their own internal staff – also showed a wide range of
relationships that appeared to run along a continuum from hostility and
conflict with most of the major stakeholders in their external milieu, through
to much more harmonious and constructive partnerships with the major
players, with examples of most points somewhere in between these
extremes.
The local organisations that took up the challenge of establishing a TC did so
for a wide variety of reasons. In addition to the generally favourable policy
environment, local motivations to open a TC were often rooted in local history
and context (for example pressure to find new capacity to treat patients on
their own or other hospitals’ waiting lists, a stalled plan to relocate surgical
services or open a day-surgery unit, the need to find a use for an underused
hospital building, the chance to engineer changes in local professional
influence, and so on), which conspired to drive each local initiative forward.
While to some extent these motivating factors were unique to each of our
sites, some common features emerged.
Firstly, the people. The decision to apply for TC funding inevitably resulted
from the resolution of a number of often conflicting views (which we have
referred to as contests of meaning). These were clearly influenced by key
players who were themselves subject to pressures from the internal and
external milieus of their organisations. For example there may have been –
and usually were – idealists who saw the TC as a chance to improve patient
care. But there were nearly always sceptics who saw it as yet another fad,
opportunists who wanted to secure the funding to develop a new service that
was in any case much needed, and pragmatists who wanted to do whatever
seemed most likely to improve the service with minimum fuss. Even where
there was consensus among those with the power to make the final decision,
there were always discrepancies about their underlying motivations,
rationales and intended outcomes, resulting in evolving and constantly
negotiated clusters of decisions that gradually emerged as something
approaching (at least) some of their initial visions of a TC.
A second unifying thread in the various reasons why these sites developed
TCs is the sense that they wanted to bring about improvements – to ‘improve
quality’, to ‘improve quantity’ and/or to ‘improve kudos’. In improving quality
some sites prioritised patient-focused approaches to care or ‘modernising’
patient processes. This included the fundamental reform of traditional clinical
practices and transformations in skill-mix. In improving quantity the case
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studies were hoping to increase capacity, throughput and activity, and in this
they were tightly coupled to a performance agenda set down by the
Department of Health, which was concerned with reducing waiting times and
increasing activity. In improving kudos for the organisation (or for individuals
within it) the sites were hoping their TC would make their organisation more
competitive, or at the very least to prevent them falling behind and becoming
uncompetitive. Some sites also used ties with external stakeholders (SHAs,
the Modernisation Agency or the Department of Health) as a way for the TC
help to improve the profile of the wider trust (or of key personnel within it).
Thirdly, all our sites experienced a variety of problems related to imprecise
planning, financial setbacks and (usually) overcapacity, and all experienced
some degree of evanescence of some of the original motivators for change,
such as the principle of nurse-led care or other shifts in professional roles. For
a variety of reasons, almost none of the TCs was able to plan and predict with
any consistency or precision even such basic parameters as the numbers and
types of patients they would treat. The way that the TC fared once it had
opened depended partly on the changing state of the local health economy,
which was shifting constantly in the maelstrom of central initiatives and the
very varied local responses to them. Many of these had not only indirect but
direct impacts on the ways the new TCs functioned (for example the financial
incentives – or disincentives – for local trusts to send them patients). The
outcome depended on how the managers of the TCs were able to respond to
this rapidly changing environment, which in turn depended on the
relationships they had with key stakeholders in their local health economies.
In this respect the TC managers and those of their host trust were, by their
responses, enacting the environment with which they subsequently had to
cope (for example, by the kinds of competitive or collaborative relationships
they established with key local stakeholders).
Despite the turmoil, however, there was often perceived to be an impact on
patient flows – such as increased throughput and a decrease in waiting lists –
and significant changes in the quality of the care that patients received.
These included pre-operative assessment done by nurses via a questionnaire,
a nurse-led clinical pathway about which patients were fully informed before
arriving at hospital, well-honed individual care pathways with key milestones
(based albeit sometimes controversially on US models), case managers in
charge of discharge planning, PCTs providing planned intermediate care, and
considerable redesign of the workforce and the physical environment in order
to accomplish these new ways of working. But often the eventual changes
were relatively superficial (‘first order’ rather than ‘second order’
transformation). By the end of the three-year study, three of the eight sample
sites remained (partially) identified with the NHS programme, one had closed,
one had been bought out by a private health care provider and three were at
some stage of becoming linked with the independent sector. Only one of
these appeared to have weathered the storm by emerging as a stand-alone
TC that closely followed the original exemplar of the policy model of what an
NHS-run TC should be.
Finally, while we have shown that it is possible mathematically to model ways
to optimise patient flows and bed capacity, the planning capacity of NHS
management in the frenetic environment in which TCs were being developed
meant that such considerations appeared much less relevant than perhaps
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they ought to have been. It was possible through our mathematical modelling
to show, for example, that there were some circumstances under which the
introduction of a TC might be predicted to offer little if any benefit to the local
health economy, and indeed that serious problems of overcapacity might
result (as in the event it did do, in just the kinds of sites that the model
predicted). Yet despite the apparent weight of such logical argument, the
local political and clinical context, motivations and environments would have
made it impossible for such a finding to carry any weight in the complex
evolution of plans, negotiations and implementation.
10.2 The ‘innovation journey’
The model of the ‘innovation journey’ has been helpful in analysing our data
(Van de Ven et al 1999). Van de Ven and colleagues in their classic 17-year
Minnesota Innovation Research Programme, which studied 14 innovations
developed in a variety of organisations mostly in the commercial sector,
observed that innovations never underwent a linear development, but took
seemingly unexpected twists and turns in a complicated and apparently
unpredictable journey from their inception to their final outcome of
implementation or abandonment. They explored whether this might be more
than just random and contingent, but rather the result of a ‘non-linear
dynamic system’; in other words, whether one might be able to identify the
components in both the innovation and its environment that might help one
predict, and therefore perhaps control, those twists and turns. As we did with
the TCs, they found fault with the conventional wisdom that an innovation
was a stable entity, maintained and developed over time, in which key
parties, having developed a consensus about the (largely technical) potential
of the innovation, carry it through the stages of its development, testing,
adoption and diffusion. Their fieldwork revealed a very different picture, one
which resonates with our own findings in Sections 4 to 7 above:
As the developmental processes unfolded, we saw innovation ideas proliferate
into many ideas. There was not only invention but reinvention; some ideas were
discarded as others were reborn. Many people were involved, but most only
partially: they were distracted by busy schedules as they performed other
unrelated roles. The network of stakeholders involved in transactions was
constantly revised. This ‘fuzzy set’ epitomises the general environment for the
innovation as multiple environments are ‘enacted’ (Weick, 1979) by various
parties to the innovation. Rather than a simple, unitary, and progressive path,
we recorded multiple tracks and spin-offs, some that were related and co-
ordinated and others that were not… The discrete identity of the innovation
became blurred as the new and the old were integrated
(Van de Ven, 1999; pp.8-9)
The ‘innovation journey’ as Van de Ven and colleagues depict it, has a
number of components that – while not necessarily happening in an orderly
sequence – take it from an initiation period, through a development period, to
implementation or termination. It was possible to detect a similar pattern in
the TC journeys. One can see an initiation period in which there was gestation
(Section 2) during which the Government formulated the programme to help
deal with waiting time and waiting list reductions, patient-centred care and
the need to modernise service organisation and delivery, and allocated extra
central funding to achieve this. There was also local gestation, in which
chronic unfulfilled aspirations to recreate the organisation or change services
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had been growing. A vital component of the ‘journey’ was what Van de Ven
and colleagues call the ‘shock’ (the sudden stimulus that catalyses the
inception of the innovation). At the local trust for example, this might be the
sudden availability of new capital funds for something new called a ‘treatment
centre’ coupled with critical events stressing the need to rebuild or revamp
the organisation (for example increased competition; failure to meet local
waiting time targets; extreme financial deficit in host organisations, or some
existential or identity crisis that the trust was undergoing.) Thus local and
national gestation factors would be transformed by the ‘shock’ into the
opportunity for a new TC. The next key component is the planning– about
which we will say much more below – which nationally involved largely
rational planning by the Department of Health and Modernisation Agency, but
which evolved as new policies were devised. Locally, planning often consisted
of business plans hastily pulled together to satisfy local and national decision
makers (equivalent to Van de Ven’s ‘resource controllers’) but not necessarily
to act as workable blueprints – another feature of the innovation journey
described in the Minnesota study. And, as in their study, the TC plans were
constantly forced to adapt in reaction to national and local policy shifts.
The components of Van de Ven et al’s second period, the ‘development
period’, comprise:
• a proliferation of varying ideas and activities (which describes very well
the diversity that we found)
• setbacks and mistakes (as is clearly evident in Section 6)
• shifts in the success criteria (for example the proportion of private care or
the changes in financial arrangements)
• changes in key personnel and key external organisations (most of our
TCs were characterised by rapid turnover of key management staff both
internally and changes among key external players)
• the creation of a trans-organisational community infrastructure of
innovators (for example NHS Elect).
Finally, during the implementation or termination period, their model
describes how the innovation links the old with the new (note for example
how in Section 6 we see that nearly all of the TCs were reabsorbed into their
host trusts); a reinvention of the innovation to fit the local situation (a main
theme of our findings); and finally the termination of the innovation as it
either becomes part of the mainstream or – as at Site F – is closed.
This very brief exegesis of the ‘innovation journey’ model shows how readily it
can be applied to the organisational innovation of TCs in the health service.
Despite the model having been derived mainly from studying the
development of technical innovations in the commercial sector, it helps make
sense of the complexity, diversity and apparent disorder that we found in our
fieldwork. And it shows that our findings were in keeping with findings from
that classic study of innovation. But in addition, we found several key aspects
of the process that figured prominently in the TC story, which are particular
features of the NHS and require further elucidation. These include:
• the general policy environment, which is now moving ostensibly away
from the top-down, target-led environment that pertained during our
study, and more towards innovation based on local initiative
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• the implications of the contests of meaning of the innovation of TCs at
the different levels of the NHS
• the nature of planning and decision making in a volatile policy
environment
• the possible place of ‘design rules’ in the innovation process
• the place of mathematical modelling in a frenetic planning environment.
We discuss each of these below before ending with a review of the TC
innovation programme against the template first put forward by Greenhalgh
and colleagues (who include two of the present authors, Paul Bate and Glenn
Robert), in an SDO-funded project in 2005 (Greenhalgh, et al 2005). First
however, we list some possible implications of our findings for the NHS.
10.3 Policy implications of the research
In this section we discuss some of the broader policy issues that place our
research findings in the likely future contexts of UK health care; we focus in
particular upon the ‘new’ model of policy implementation that is currently
emerging. One particular facet of this model is an apparent shift away from
‘top-down targets’ to a ‘local innovation and incentive-led’ framework, and we
consider the implications of this change for organisational innovations such as
TCs.
10.3.1 The concept of innovation within the ‘new’
Government framework: from top-down drivers to local
incentives Beyond the specific policy initiatives described in Section 5 there has also
been a shift (or at least an espoused shift) in the broader underlying
assumptions and approach to policy implementation in the NHS. The NHS
Modernisation Agency, initially responsible for implementing the TC
Programme nationally, has been closed down, and we are learning more by
the day about a ‘new’ Department of Health, committed to moving away from
the NHS from a directive, top-down, target-driven organisation based on
performance management and the vertical pressures of hierarchical line
management (‘model 1’). Although this constrictive model has been described
by Hoque and colleagues (2004), who were studying a foundation hospital
trust, as leaving very little room for managerial autonomy despite all the
rhetoric about devolution, our case sites were mostly able to find considerable
local latitude while still apparently conforming to central diktat (see Sections
4-7 above, and Pope and Robert et al, 2006). Be that as it may, the current
policy seems to denote a transformation to a combination or hybrid of two
further models:
a the lateral pressures of the commissioners in a commissioner-provider
organisation, where the vertical lines are loosened and performance
management becomes contract management (‘model 2’)
b a bottom-up model based on competition between providers and
pressures upwards from patients as choice becomes a major incentive for
innovation and improvement (‘model 3’).
Greener (2004a; p.673) attributes the latter to a phased shift in New Labour
policy since 1997, which has seen the chosen ‘driver for change’ moving from
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‘quality’ through ‘performance’ to ‘choice’, the most recent of these reflecting
a:
…far more explicit model of health consumerism in place than ever before,
placing Patient Choice before even medical expertise, and placing a serious
challenge to the latter. Patients have gone from being passive recipients of
health policy, to being expected to drive change on behalf of the state.
(Greener, 2004a)
The recent NHS Operating Framework for 2006/7 confirmed the change of
‘driver’ from ‘targets-driven’ to ‘incentives-driven’, expressing it thus:
…[a commitment to] reform the health system fundamentally, so that change is
driven more by incentives to respond to patients than by top-down target
setting… old methods of top-down performance management will not be
sufficient to deliver this
(Department of Health, 2006b; pp.2-3)
Indeed, so as to leave no doubt, the Department of Health proceeded to
reinforce this comment with a striking graphic which made explicit reference
to the idea of ‘local innovation’ (Figure 35). However, as we have argued
elsewhere (Pope and Robert et al, 2006), the Government’s original rationale
for TCs was clearly target-led and therefore to the left of the figure; the aim
was to significantly reduce waiting times as part of the drive to improve
patient care (for instance, the NHS Plan argued that the separation of elective
and emergency care afforded by TCs would allow them to ‘concentrate on
getting waiting times down’). Targets of a maximum three-month wait for an
elective admission were set and TCs were seen as a vital mechanism in
achieving these targets. Placing the macro-level management of TCs under
the umbrella of the Department of Health Waiting, Booking, Choice
programme underscored this. In contrast, while the defining characteristics of
a TC provided by the Modernisation Agency resonated with the Government’s
ambition to increase productivity and thereby reduce waiting lists, these
drivers were not quite as central for the Modernisation Agency because their
main aims were ‘modernisation’ and supporting front-line staff to think and
act differently. The Modernisation Agency’s representation of the TC concept
was shaped much more by their focus on improvement and embedded with
the stylised language and terminology of NHS modernisation (for example
‘redesign’, ‘radical’, ‘empowerment’, ‘innovative’ and ‘new ways of working’)
and therefore somewhat nearer to the notion of ‘local innovation’ as
represented by the right of the figure. How NHS TCs sought to juggle and
balance these different change pressures became an integral part of the local
management and developmental process.
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Figure 35 From a ‘targets-driven’ to an ‘incentives-driven’ approach
Source: Department of Health, 2006b (The NHS in England: The operating framework for 2006/7)
Thinking about innovation and change more broadly
Recent research funded by the NCCSDO R&D programme (Greenhalgh et al,
2005; p.82) helps us to conceptualise this shift in the approach to innovation
and change in broader terms by proposing a continuum of the contrasting
traditions of what innovation is and how it spreads in service organisations,
such as health care (Figure 36). As Greenhalgh et al note (ibid; p.80), there
is a ‘vast range of research traditions whose work has a bearing on the spread
and sustainability of innovation in health service organisations’. Figure 36
seeks to represent these traditions in terms of:
a the level of intervention (from ‘let it happen’ to ‘make it happen’) that
they assume beneficial (and possible)
b the defining features of the various traditions
c the assumed mechanisms by which innovations spread according to the
traditions
d the types of metaphors used by the research traditions to describe the
spread of innovation.
In terms of representing the emerging ‘new’ Department of Health, model 1
as described at the start of Section 10.3 would sit over to the right of this
continuum among the linear and rationalist conceptual models in which an
innovation is a ‘thing’, adoption is an ‘event’ and implementation is a rational,
controllable process that is amenable to advance planning and monitoring
against targets’ (ibid; p.81). The introduction of TCs (Section 2) was
somewhere between this ‘make it happen’ and the ‘help it happen models’. To
the left of the continuum lie the models in which ‘innovation, adoption,
implementation and sustainability are complex, context-dependent and
creative social processes that cannot be planned in detail and are not
amenable to external control or manageability’. A combination of models 2
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and 3 (reflecting the Department of Health’s new position that ‘change is
driven more by incentives to respond to patients…’ would sit somewhere
roughly between the ‘help it happen’ and ‘let it happen’ points on the
continuum (although nearer to the former than the latter). Viewed in this
way, the shift in the paradigm and theory of innovation and change appears
to be fundamental, leading one to question whether it is more or less likely to
offer fertile ground for service innovations to grow and flourish.
Figure 36 Different conceptual and theoretical bases for the spread of
innovation in service organisations
Source: Greenhalgh et al, 2005
Significantly, TCs in the NHS have evolved as an organisational innovation
just at the time when this shift in approaches began to take form in health
care policy-making; some of the confusion and uncertainty as related by our
case study sites and described in earlier sections in this report would seem to
reflect the inherent tensions between these different models.
Differing ‘frames’
One vital but as yet unexplored aspect of this tension between ‘make it
happen’ and ‘let it happen’ is the rather important question of what the ‘it’
actually is. We found that there were major differences between the concept
of a TC as envisaged by key actors at different levels in the NHS, across
different professional groups (including, of course, managers) and between
the groups we have called idealists, opportunists, pragmatists and sceptics
(Section 3). In examining and comparing the variety of local incarnations of
TCs with each other and with the ideas expressed across different levels and
groups as to what a TC was, we drew on ideas developed by Erving Goffman
around frame analysis (Goffman, 1974; Snow et al, 1986). We have
suggested elsewhere (Pope and Robert et al, 2006) that the innovation called
‘TCs’ was created by interconnections and interdependencies of meanings
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operating at different levels in the health system, for example the macro (for
example Department of Health) policy level, mediated by a meso (for
example SHA) level (House et al, 1995) and implemented at the micro-level
at each local TC. The idea of ‘framing’ suggests that the frame or definition of
the meaning provides conceptual or cognitive structures which shape both
how TCs are viewed and, in turn, how they are enacted.
We identified three frames of particular interest to the study of TCs: the
Government frame, the modernising frame and the TC frame. The
Government framing of TCs (described in Section 2.2), provided the
definitional components; it centred on separating emergency and elective
services, delivering faster services with increased throughput, and
encouraging the use of both private sector and NHS facilities. Its rationale
was to reduce waiting times and import new ways of delivering care. The
modernising frame (described in Section 2.3) was more clearly focused than
the Government frame. It set out, for example, to list the core characteristics
of a TC (Section 1.1). Yet on closer inspection, the list was not only vague
(for example it never defined ‘high volume’ activity) but also shifted subtly
over time. This allowed our third, local frame to create and recreate different
meanings which, as is described in Section 6 (et passim), were very varied
solutions to local organisational problems.
These are just three of a potentially long list of existing or potential framings
of TCs, but they provide examples of frames that we see as having been at
once distinct and interconnected during the early phase of TC evolution.
These three frames surrounding TCs are located at different organisational
levels: the government frame expressed at the macro level of health policy
and politics, the TC frame rooted in the micro level implementation, and the
modernising frame, we suggest, mediating the other two. This latter function
was carried out by the Modernisation Agency (although regional offices, SHAs
and NHS Elect might also be said to have a variety of other meso-frames). In
this sense, ‘meso’ refers not simply to a middle layer of the organisation but
one that, for example in terms of allegiances, can be more or less allied in
various ways to the macro and micro frames. In fact the Modernisation
Agency in its earlier phases was much more closely allied to the centralised
macro level policy-making than to the local TCs’ frame.
All three frames had some common features, such as the separation of
elective and emergency care, but in fact the commonalities were remarkably
few. The macro-frame of the Department of Health had its origins (Section 2)
in the Department of Health’s responsibility to provide advice and execute
ministerial policy, and was situated within a wider context of a large-scale
political programme of health service and public sector reform directed by the
Labour Government since 1997. Thus the Department of Health macro-frame
encompassed a number of other key health service initiatives (Section 5)
such as Patient Choice and the independent sector TC programme. Within
that frame it therefore made perfectly good sense for the Department of
Health (like the Government in its own macro frame, which was related to but
not the same as the Department of Health frame) to see the TCs as part of
that package of initiatives. In contrast, the micro-level frame of the local TCs
encompassed a quite different set of concepts and activities, shaped by the
milieus and the motivators described in Sections 3 and 4, such as
redevelopment of local day surgery, competitive advantage, income
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generation, or an alteration of patient-booking methods. From within this
frame the plethora of initiatives that represented the macro frame made very
little rational sense; it was just a flurry of ‘must-do’s’ with little or none of the
consistency that was apparent to the politician and civil servant originators of
those policies. The Modernisation Agency’s meso-frame, while sharing some
of the aspects of both macro and micro (for example Patient Choice, new
booking practices) – also differed from them by having less of an emphasis on
other aspects (for example private provision or on local income generation).
Rather, it focused on streamlining services, improving the patient pathways
and re-engineering professional roles, and on sharing and disseminating best
practice (see Section 2.3.1). Thus each frame had its own (often implicit)
definition, rationale, and image/identity, terminology and above all its own
interpretation of the meanings of phenomena associated with TCs. And each
frame had its own concatenation of associated values, concepts, policies and
activities. The crucial point about frames is that they at once define and are
defined by all these phenomena. And of course the same applied not only to
the three frames that we have exemplified here, but also to other frames
such as the SHAs and regions (Section 4), and to groups such as managers
and doctors (Sections 3 to 6), or idealists and sceptics (see Section 3.4).
We found that the differences between the frames had major consequences
for the interactions between the key players, which informed many of the
variations that resulted in both the reality and perception of the innovation
(Sections 6 and 7). Contests of meaning were a crucial part of the evolution
of the TCs as described particularly in Section 6, whose formulation – or
‘innovation journey’ (Section 10.2). – was the result of these conflicting
interests and forces (described in Sections 2, 3 and 5) pulling in differing
directions. And that result, of course, was dependent not only on the direction
of those forces but on the political and organisational weight that their
protagonists could bring to bear. This, moreover, is closely related to the
general policy environment discussed above, namely whether the power lies
mainly at the centre or with local innovators. And this of course means in turn
that the proposed replacement of a top-down approach with local incentive
frames will have an important bearing on innovation journeys; (as well as
inevitably being very differently perceived within different frames!). We
therefore return to the implications of that general shift in the policy
environment, but now with the added insight that when central and local
players tussle over an innovation, making, letting or perhaps preventing ‘it’
from happening, they each perceive a different ‘it’ from within their various
frames.
10.3.2 Likely implications for service innovation and
improvement
The vision upon which the shift from ‘top-down target-led’ to ‘local innovation
and incentive-led’ is based was initially set out in Health Reform in England:
update and next steps, written by the new Department of Health Policy and
Strategy Directorate and published in December 2005, and it is to this that
we need to turn for the details, all of the time considering the possible
implications for TCs and future organisational innovations, and what we know
from previous research as well as what we have learnt from our own study.
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The document in question outlines a new model for policy development over
the next three years, orientated towards the final phase of the Government’s
10 year modernisation plan. Its whole tone is about abandoning the top-down
approach (model 1) and recognising that while the centre cannot direct or
manage innovation and change, it can and should be seeking to enable,
motivate and regulate it (in the words of this study, create a receptive
external milieu or context). In line with this, Ferlie et al (2006; p.67) point
out that ‘academically, the role of strong incentives in interacting with and
reshaping organisational tracks has not been considered fully in prior change
management work in health care… perhaps because previous incentive
structures have been relatively weak’. They also suggest that ‘the role of
incentives is neglected in the change management literature which is more
sociological in character and assumes that incentives will be too weak to
change embedded behaviour’ They go on to suggest that an organisational
economics perspective may have greater value in the future.
The Government’s aim – as outlined in Health Reform in England – is to
create a ‘self-improving,’ ‘self managing’ NHS, and significantly for TCs and
other innovations, ‘to achieve an in-built dynamic for innovation and
improvement’ (p.10), and ‘providers with more freedom to innovate and
improve services’ (p.6). Other relevant phrases include ‘greater local
involvement and self determination’ (p.9), ‘empowering people locally’ (p. 9),
‘a self-improving NHS led by patients and the public in partnership with staff’,
‘rule based to incentive based… new incentives to enable health care
professionals and NHS managers to better respond to the needs and
preferences of their patients’ (p.7), and ‘flexibilities within a context of
system rules’ (p.8). Most of these are covered by the so-called ‘supply side
reforms’ indicated by the right hand box of the Department of Health’s new
model below (Figure 37) and its accompanying annex (see Appendix 7) which
appeared in the same document. All of this seems aimed at giving providers
and innovators and change agents such as our eight case study trusts and
front-line professionals and local managers such as the TC staff within them
‘the incentive to improve services in response to the needs of their patients
and local populations’ (p.20).
So what are the likely implications and prospects of these recent policy and
governance developments both for the future of TCs and for service
innovation and improvement more generally within the NHS? What will the
words mean in practice, if anything, and will they make a difference in terms
of the ‘doing’ of organisational innovation and change? If our TCs had been
introduced into this kind of context might they have evolved in different ways
and might they have had any greater or lesser impact, and chance of survival
or expansion? Will the context or milieu become more or less ‘receptive’ as a
result of this change of policy context? How might the new profile alter the
dynamics of innovation and improvement as they get played out in the many
ways we have described, or indeed alter the manner and direction in which
innovations like TCs develop, and their resulting impact on quality, efficiency
and effectiveness of care? None of these questions is hypothetical. This is the
policy context in which our surviving seven TCs now find themselves, and in
which any new or current TCs, public or private, will have to operate; the
implications for practitioners that arise from this changing policy context are
discussed below (see Section 10.4).
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Figure 37 Framework for the reforms
Source: Department of Health. 2005. Health reform in England: update and next steps
The first thing to note (a recurrent theme in this report) is that there always
was considerable variation between TCs locally, and between what central
Government (the Department of Health and the Modernisation Agency)
wanted/expected and what the TCs locally were prepared to give them see
Pope and Robert et al, 2006, for a further discussion). This is despite the
existence of ‘Big Brother’ model 1, which suggests to us that, if the TCs are
anything to go by, the Department of Health was wise (and perhaps had little
choice but) to abandon a model which had clearly already lost much of its
directive power! De facto, and some would say perversely, our TCs therefore
displayed many, if not most, of the features of the new ‘local innovation’
model even before it was introduced, a case perhaps of policy following (and
legitimising) practice rather than leading it. For instance, Ferlie et al (2006,
p.71) – in their study of seven health care providers engaged with London
Choice – found that ‘some of the diagnosis and treatment centre capacity was
pre-existing and relabelled for choice’. This finding was corroborated in a
number of our case study sites.
It still needs to be asked, however, (not least for fundamental reasons of
governance) how did a clearly prescribed policy initiative give rise to such
diversity of product and outcome? TCs were given a clear policy objective
(that is, the reduction of waiting times), a set of principles related to their
development (the Modernisation Agency’s desiderata) and a timeline to do it
in. Yet they all evolved differently from vision to product, (some rapidly, some
more slowly, some never), clearly constructed to suit local needs and agendas
rather than any national blueprint, and striving to stand out from each other
as much as to conform – an innovation terrain thus marked by colour and
diversity rather than any discernable policy monochrome.
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Is this really any surprise, however? Pressman and Wildavsky’s (1973) classic
study of policy implementation explored the efforts of the US Federal
government’s Economic Development Administration (EDA) to create jobs for
the long-term unemployed in Oakland. The research showed how the EDA’s
attempts to implement policy in Oakland suffered setbacks that were not only
costly but typical of the problems encountered in federal-local projects. The
authors suggested four possible reasons for central objectives not being
realised. One explanation is the assertion of faulty implementation. Another
explanation may be that aspirations were set too high. Thirdly, the possibility
of a mismatch between means and ends calls into question the adequacy of
the original policy design (perhaps implementation was good but the theory
on which it was based was bad). Finally, could a different set of initial
conditions have achieved the predicted results? Warren (1974) further
suggests that the most important maxim to be learned from their tale of
programme failure is that ‘implementation should not be divorced from
policy’:
In other words, programs fail too frequently because too much respect, effort
and enthusiasm are given to program design, obtaining initial support from the
participating community and funding, while the implementation stage is
regarded as the easy part involving only routine, technical questions that can
always be worked out later as long as the program itself is sound …
Commenting on the Oakland failure, they [Pressman and Wildavsky] assert
‘…these seemingly routine questions of implementation were the rocks on which
the program eventually floundered’.
(Warren, 1974; p.1090)
While not all our case TCs could be described as having ‘floundered’ to quite
the same extent as the EDA programme (though some quite clearly could),
the above characterisation of the discrete attention typically paid to the
‘policy’ and the ‘implementation’ phases (see following ‘implications for
practice’ section) of organisational innovations in the public sector resonates
strongly with our own findings. Clearly there was a hiatus between top level
policy guidance and advice in terms of TC form and process, which was not
helped by the dissolution of the Modernisation Agency and its TC team
midstream, and the reorganisation of SHAs, both of which tended to remove
whatever weak ‘meso’ connectors already existed. The innovation literature
has spent a lot of time looking at the issue of co-ordination and autonomy,
but not this — in our view equally important — issue of connection. In our
opinion this merits more attention than it has attracted to date particularly in
multi-level organisations like the NHS where such connectors are the only
means through which it operates as an ‘innovation system’ rather than
collection of fragments.
Brooks and Bate’s (1994) analysis of a change programme in the British civil
service in the late 1980s/early 1990s found a similar picture of
underachievement where the local context acted against top-down attempts
to introduce transformational change. In their proposed matrix of possible
scenarios for a change programme they suggested that the British civil
service was unlikely to move towards transformation (planned or unplanned,)
but that it would either stay the same or take on less radical elements of the
change programme. More recently – and more immediately relevant to the
NHS context – Exworthy et al’s (2002) study of the adoption of policies to
address health inequalities in the UK again bears remarkable similarity to the
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findings of our research into TCs. They found that although national
policymakers viewed policies to reduce health inequalities as an innovation
developed and supported centrally (and intended to be disseminated
vertically for adoption at the local level), and although there was strong
alignment in the values underpinning both central and local policymaking on
inequalities, there was little or no direct vertical cascading of this policy. In
reality, what central Government saw as uptake of the ‘innovation’ (policies to
reduce inequalities) was actually a rebranding of existing initiatives to fit the
new category (and new budget) assigned to ‘inequalities initiatives’). [Note
that this commentary on Exworthy et al is drawn from that of Greenhalgh et
al (2005; pp.173-174), two of whose authors were also authors of this
report.] Such disconnections between central policy and implementation as
revealed by Exworthy’s – and now our – research raise big questions as to
what the role of central Government is and should be, given that at least in
the area of innovation it appears not only to have lost its directive power but
seems to have relatively weak influence upon what happens locally. The
implication for central policy must be that it needs to concentrate on framing
implementation (setting boundaries and common rules and frameworks)
rather than trying to directly determine it.
That being said we cannot simply dismiss national policy as always irrelevant
or of no help or consequence – as indeed the TC programme showed if only
by giving impetus, headroom and resources to new initiatives on the ground .
The systematic review of the diffusion of innovations in health service
organisations by Greenhalgh et al (2005; p.14), although not intended to
focus on the policy making/implementation literature, reported on several
empirical studies which measured the effect of the policy context on the
adoption of a particular innovation. The review found that:
A policy ‘push’ occurring at the early stage of implementation of an innovation
initiative can increase its chances of success, perhaps most crucially by making
a dedicated funding stream available. External mandates (political ‘must-dos’)
increase the predisposition, but not the capacity, of an organisation to adopt an
innovation; such mandates (or the fear of them) may divert activity away from
innovations as organisations seek to second-guess what they will be required to
do next rather than focus on locally generated ideas and priorities.
This describes what we found with the TCs: it will be recalled that not only
significant amounts of capital funding for new buildings and the renovation of
existing facilities, but also other significant ‘slack’ resources were made
available by central Government to those seeking to implement a TC locally.
The latter included, for example, the Modernisation Agency programme, NHS
Elect (see Section 5) and more recently funding for the AmbiCentres
International initiative. [Note that AmbiCentres was formed in 2004 to ‘carry
forward our faith in the provision of health care through treatment centres’
and its website contains a database of TCs, a library to support best practice
and a forum for anyone interested in TCs. As such it has a key role to play as
one of the few remaining ‘connectors’ in the TC process (see
www.ambicentres.net).]
Thus it could be argued that the direction and support from central
Government for the TC programme did in fact do quite a lot to ‘help it
happen’, had it not been that so many other initiatives made it almost
impossible for it to happen as anyone had originally envisaged. Moreover it
could also be argued that in such circumstances, it was inevitable that local
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solutions would need to be found that moved towards the initial ideal of a TC
while also trying to optimise movement towards many other ideals that were
sometimes not only pulling in different – indeed contrary – directions, but
creating elephant traps.
Taking the new policy context at face value we can view TCs and future
service innovations in the context of what we perceive from the key
documents (Department of Health, 2005f; 2006b) to be five main conceptual
components that make up its core. We see these five as being a rules-based
system, incentives, freedoms, performance and patient involvement and
patient-centred services. Any or all of these components, we suggest, might
shape the nature of these innovations and the direction they may take in the
future. As there remain so many unknowns we have chosen to illustrate the
range of potential issues raised by this ‘new’ policy context by focusing on the
first two of these five components. Much of the following is in the form of
questions for further consideration by policymakers and researchers.
a) Rules-based system
The first component of the new policy stresses the move to a rules based
system, recognising that any national policy guidance ‘can only set the
parameters within which local organisations will work’ (Department of Health,
2006b; p.3). Perhaps a new and more constructive way of conceiving such
system rules – and a useful way of moving away from the traditional
‘rule=obligation’ or directive mindset – might be in the form of ‘design rules’
for innovation’ (Bate and Robert, 2007; Bevan et al, 2007; Plsek et al, 2007).
These would consist of the imperatives and ‘must do’s’ distilled from
experience and practice which enable one to say: ‘If you want to achieve
outcome (for example, encouraging local innovation) Y in situation S,
something like X might help’. Viewed as design rules rather than behavioural
rules the emphasis moves from a mindset of control (which many perceive in
negative terms) to knowledge, positive learning and evidence about what has
worked, and more importantly why and how it has worked in the way that it
has.
This idea of positive – ‘glass is half full’ – mindset has created a whole new
area of research and practice known as ‘positive organisational scholarship’,
which its advocates argue is a transformative mindset especially for
bureaucracies and bureaucrats such as the NHS. Certainly, a positive
organisational scholarship approach to TC innovation would have been very
different from the one that we observed, with far greater emphasis upon
possibility and the abundance of opportunity and far less on scarcity, negative
politics and constraint (see Cameron et al, 2003). Such an approach pushes
all interested stakeholders to ask:
• Are there design principles for implementing organisational innovations
in health care, including TCs? If so what are they?
• What are the key considerations to be borne in mind?
• What are the tried and tested design exemplars (for something like a TC)
that we already know about?
Answers to such questions are most likely to come from those who have close
experience of managing the innovation in question. Part of the work of the
Modernisation Agency during the duration of our study could be represented
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as working with such managers to seek out the answers to questions about
‘what’ design principles had worked. However, in the case of TCs, they were
not able to get to the heart of ‘why’ and ‘how’ those principles succeeded or
not. Thus at the learning events, for example, where it might have been
possible to reflect on the details of how and why some design rules worked or
not, and to develop them collectively, there was reluctance to do so. The
events were carefully stage-managed and if there was a sharing of the deeper
concerns and why and how of developing TCs, it happened mainly in the
informal networking, and not as part of the explicit sharing of practice.
Perhaps in a performance-driven, competitive NHS, the Modernisation Agency
and the TC managers were careful not to delve too deeply in their ‘learning
events’ for fear of disturbing the illusion of a shining innovation and bringing
shame upon one’s own house. Instead, the public processes seemed to us to
collude in ‘keeping up appearances’ rather than genuinely striving to develop
realistic design rules. Yet at other (non-Modernisation Agency) fora, we heard
chief executives and senior clinical managers delivering polemics about the
adversity of the environment and its effect on the TC – to the extent of
showing graphics depicting ‘the perfect storm’ to describe the totally adverse
policy context that they felt was overwhelming the TC initiative.
If neither the Department of Health nor the Modernisation Agency were – for
whatever reason – unable to foster the collective development of design rules
during the period of our study, then who in the new-look NHS will be
responsible for creating and implementing the new rules? The Department of
Health is in no doubt:
There will be a great responsibility on new strategic health authorities (SHAs) to
ensure than guidance is implemented locally, that the new system and
organisations [PCTs and\ Foundation trusts] are developed rapidly and
effectively, and that problems are successfully managed locally.
(Department of Health, 2006b; p.3)
Apart from observing that the tone of the above clearly remains compliance
rather than commitment based, we also need to ask – challenge – whether a
future SHA driven, rules-based system that holds organisations accountable
for what they do should be any different from what has preceded it. For
example we have seen how marginal the SHAs and PCTs have often been in
TC development (due in part to the central commissioning process that
characterised the early implementation stages of both NHS and independent
sector TCs). One other reason, revealed in our interviews with external
stakeholders, was that these organisations were themselves at an early stage
of their development and they were unclear and uncertain about what their
role should and could be, and what it could realistically deliver. On current
evidence, these questions have not gone away, and it remains to be seen
whether SHAs will ever be able to accomplish such a sea change.
To put these real life issues in a conceptual context, recent literature makes
the point that innovation processes and outcomes depend upon how an
organisation deals with the ‘coordination-autonomy’ dilemma (Puranam et al,
2006). That is to say, how might the NHS deal with the competing pulls
between the need for coordination mechanisms such as standard operating
procedures, routines, and shared language that enable mutual learning and
‘system gains,’ and the need for autonomy and the incentives this gives
people to take the necessary initiatives to innovate and try new things.
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Clearly the new policy and governance arrangements are seeking, as always,
to deal with the necessary balances and trade-offs between them but it is too
early to say how this will ultimately resolve itself. Arguably in the past, and
despite the powerful unitary intentions of the centre, there may have been
rather too much autonomy beneath the regional/SHA level, leading to
fragmentation and loss of some of the gains that might have been made as
the result of the stakeholders in the local health economies working more
closely together on specific issues such as TC development. This may seem
surprising to some observers who claim that the Department of Health has
been too ‘hands on’. But our observations of the development of TCs suggests
that, paradoxically, it was the very plethora of central directives (and the lack
of a core of common design rules) that made it essential (and possible) for
each locality to steer its own apparently autonomous course – the course that
seemed to local managers most likely to optimise the achievement of their
particular confluence of conflicting demands.
A design-rules-based approach such as we have described might give clarity
on both sides: clarity for the SHA in framing design rules which, being broad
and confined to the ‘what’, take nothing away from local autonomy in
deciding the detail and the ‘how’ but at the same time establishing clear
parameters for accountability, but also organisation design. But it would also
bring welcome clarity for TCs, if it could avoid too great an emphasis upon
benchmarking and prescriptive detail (which in the case of the TCs often got a
negative reaction) and also reconcile the twin pulls of advice, guidelines and
support on the one hand, and targets and performance management on the
other, which the Modernisation Agency, as with so many other Modernisation
Agency programmes at the time, never really managed to do.
b) Incentives
The modern idea of an incentives-driven rather than targets-driven NHS
raises an interesting question about what, if any, difference this might have
made to the way TCs have developed in the past and how they will develop in
future. So, what are the mechanisms for those incentives in the specific
national policies that have been introduced to encourage – notionally at least
– the development and operation of TCs and other forms of local innovation
and service improvement? We find three main mechanisms: practice-based
commissioning, Payment by Results and Patient Choice.
Practice-based commissioning: The aim of practice-based commissioning
is to give primary care practices the freedom, support and incentives they
need to improve care and services for their patients, within a governance
framework that ensures value for money and fairness, the priority being to
achieve universal coverage by December 2006. We saw in a number of our
case study sites a recognition of the importance of marketing TCs much more
effectively (and directly) to GPs, although the building of strong transactional
relationships had not really begun in most cases. Whether the necessary skills
and resources for such marketing will be found is open to some question,
although a number of our TCs had begun to establish a marketing function
within the TC or wider trust.
Payment by Results: The Payment by Results system aims to reward
quality and efficiency of both commissioning and providing, and will involve
planning, coding, costing and scheduling systems, and performance data and
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monitoring that are far more rigorous and transparent than many of our TCs
seemed willing to provide, or capable of providing, at the time of our study.
Therefore, not only is this likely to represent a push towards the greater
professionalisation of TCs, it may also help to create closer and more mature
relationships between commissioners and providers, which again were
missing in a number of our TCs. On the other hand, some TC managers
believed the way that the calculations on costs are done (that is, based on
aggregated and averaged figures) would unfairly favour some sites over
others, and therefore contribute to their sense of an ‘unlevel playing field’.
Patient Choice: The Department of Health’s intention is that giving patients
more options and increasing competition between providers will act as an
incentive for providers (including TCs) to innovate and achieve higher levels
of performance in terms of quality, service efficiency and activity levels (Bate
and Robert, 2005; Ferlie et al, 2006). Of course, patients did already have
some choice of TC during the period of our study (see Section 5), which for a
whole range of reasons – discussed in passing here and in more detail
elsewhere (Bate and Robert, 2006; Exworthy and Peckham, 2006) – many
patients chose not to exercise. This in itself raises some doubt as to how far
choice will act as an effective incentive mechanism in the context of TC
development in future, particularly new ones where there is no previous
patient association, affiliation or history of attendance. However, 2006/7 will
be very different from the previous three years, and a big step forward is the
extension of Patient Choice from the currently prescribed minimum of four
hospitals to also include any NHS foundation trust and, significantly for this
study, ‘any nationally procured independent sector treatment centre, and any
other subsequently centrally accredited independent-sector providers’
(Department of Health, 2006b: 9). Waves 1 and 2 of the independent sector
TC programme were expected to deliver more capacity and choice for NHS
patients, and all of the wave 1 centres were expected to be operational by
2008, delivering two million diagnostic procedures and approximately
250,000 episodes. The programme was expected to include elective surgery,
and ophthalmic, orthopaedic and general surgery, in addition to significant
levels of diagnostic testing. However, the recent decision to cancel seven of
the 24 planned local independent sector TCs (£550m of work per annum)
because ‘the Department of Health was forced to acknowledge claims by
SHAs and PCTs that more elective capacity was not needed in their regions’
(Health Services Journal, 2006) reflects many of the earlier doubts expressed
to us in our research about the desirability of such a rapid expansion of
elective capacity in some areas of the country. The remaining 17 schemes
have been delayed for up to a year. Ferlie et al (2006; p63) point out that
‘choice necessarily implies the existence of surplus capacity so consumers can
‘shop around’ and ask whether ‘health care providers [can] speedily produce
the substantial additional capacity needed’ Our findings would suggest that
yes, they could and in fact that expansion in capacity (in both the public and
private sectors) has in fact run some way ahead of the implementation of the
Patient Choice agenda itself; leading, in part, to the decision to cut back on
expansion in the private sector in some geographical areas in England.
This also takes us back to assertions made by several people that we
interviewed in our TCs that the competition with the independent sector was
not being held on a level playing field. If this indeed turns out to be the case
(as it sometimes – see Section 6 – already has), then it may doom many
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NHS-run TCs in the longer term, especially those currently suffering from a
patient famine. Clearly, an incentive will only be an incentive if those involved
perceive some chance of winning or even equalising during the ‘game,’ and
some balance between the sides in terms of numbers, resources and rules –
which is not how many have seen the situation to date (another barrier to
positive organisational practice). A related point is around the question of the
‘diagnosis’ part of the original diagnosis and treatment centres. We have seen
how the ‘D’ disappeared quite early on from the NHS-run TCs (in some cases
just a name change, in others a real shift away from diagnostic work or a
narrowing of ambition). However, the wider independent sector TC
programme will clearly be providing high volumes of diagnostic work in the
future, in so doing reintroducing an aspect of this innovation that had been in
danger of being lost (and remains so at least from the majority of NHS-run
TCs; again this may have implications for their ability to compete with
independent sector TCs in the future).
From a policy point of view it is therefore worth questioning whether, in the
present context, competition between TCs in the NHS and the independent
sector will provide the ‘in-built dynamic for innovation and improvement’ and
the ‘self-improving NHS’ that the Department of Health is looking for, or
whether policy – if it genuinely wishes to promote NHS-run TCs – needs to
support a fairer ‘game’. But even if the playing field were level, as we will see
in the next section, Patient Choice has potentially profound implications for
the way in which a TC might operate – implications that have so far been
ignored by policymakers.
10.3.3 Research and policymaking in the NHS: modelling
and the conflict of policies
The following section is grounded in the results presented by the quantitative
modelling reported in Sections 8 and 9. In the discussion, one key theme
emerges, albeit in different guises, from both the qualitative and quantitative
strands of the research – the problem presented to organisations by
unpredictable variability. Another theme is the need for a ‘whole-system’
approach in evaluating this innovation in the delivery of health care services.
Having illustrated how some of the components of the new Department of
Health policy context seem likely to impact upon organisational innovations in
the NHS in the coming years, we now conclude our discussion on the
implications for policymaking on the future of TCs by briefly discussing the
extent to which it is possible to influence policy implementation through early
evaluation. This section draws on work by two of the authors of this report
(Gallivan and Utley) with regard to the planning of the early pilots of Patient
Choice and the likely implications of this policy for the NHS TCs as predicted
in 2002. It is worth noting that these debates are part of a wider discussion
about the very notion of implementing ‘evidence-based’ policy making (see
for example Black, 2001; Sanderson, 2002; Bate and Robert, 2002; Bate and
Robert, 2003; Saetren, 2005; Learmonth and Harding, 2006).
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Predicting clashes of policy: evaluation of policy prior to
implementation
In Section 6 we described how two of our study sites had expected to treat
many more patients under Patient Choice than they eventually did. The
problems encountered by these TCs were predictable. Indeed in 2002, as part
of an exercise carried out in preparation for a pilot of Patient Choice, Gallivan
and Utley (2002b) made two key observations:
1 A system in which patients are guaranteed a choice concerning where
they are treated inherently requires more capacity to be available than is
actually used.
2 By requiring participating centres (including the two study TC sites) to
commit to reserve certain levels of capacity but only reimbursing them
for the number of patients treated, the pilot of Patient Choice was
transferring a degree of risk onto the participating centres.
It should be noted that these observations were made prior to the
implementation of the Patient Choice pilot and before any empirical evidence
was available. Instead, they were based on a process of thought experiment,
guided by the experience of how complex systems tend to behave.
Quoting directly from Gallivan and Utley (2002b) discussing the feature of the
pilot of Patient Choice whereby participating centres made a commitment to
provide a certain level of capacity:
However, there might be circumstances where this is likely to be prohibitively
expensive if [participating centres] are remunerated for capacity reserved rather
than patients treated. If, on the other hand, remuneration is made purely on the
basis of patients treated, managers at [participating centres] may well be
reluctant to reserve the requested amount of capacity, as the majority of it is
likely to go unused.
In the event, it seems that managers at the TCs affected were, perhaps
unsurprisingly, unaware of the risk to which they were being exposed. A
parallel can be drawn between this feature of the pilot of Patient Choice and a
potential clash between the policy of Patient Choice (which has an intrinsic
requirement for more capacity to be available within the system than is
actually used (Gallivan and Utley, 2002b; 2004) and Payment by Results
(that reimburses providers on the basis of activity).
In addition to further illuminating the challenging environment in which our
sites were operating, the fact that such difficulties had been predicted prior to
the event raises an interesting question concerning the role of mathematical
modelling and operational research with respect to health service operation.
We discuss below how no amount of rational planning, however sophisticated,
can fully equip those charged with implementing change and innovation in an
organisation as complex and unpredictable as the NHS. While the use of
mathematical models of the type discussed in Section 8 could help managers
to take account of some aspects of unpredictable variability in their planning,
there are intrinsic limits to the extent to which such models can reflect all the
complexities of real life, and what will work. However, mathematical models
can be extremely useful in predicting what will not work and identifying
hidden pitfalls. This is particularly the case prior to a policy being
implemented when evaluation cannot be based on standard methods of data
collection and analysis.
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It is interesting to draw a comparison between health care and transport
planning, another area concerned with providing a large scale and complex
public service. Before the introduction of any major change in a transport
system, huge amounts of high quality mathematical modelling and
operational research and planning is carried out. Major research centres, such
as the Transport Research Laboratory have been established, employing
hundreds of scientists whose work focuses on the topic of transport and there
are many more working in local authorities and the private sector.
This is in contrast with health. Certainly there is massive research funding for
biomedical research, but when it comes to evaluating health policy changes,
there are relatively few centres with the capability for carrying out relevant
mathematical modelling. Even when it is applied and highlights potential
problem areas, the results seem unwelcome. One piece of work (Gallivan and
Utley, 2002a) carried out for Patient Choice indicated many difficulties that
might arise, many of which came to pass (for example the potential
promotion of cartel arrangements, the provision of incentives to defer
treatment, quality migration, the ‘uneconomics’ of scale, chaotic queue
behaviour, the potential restriction of access, the funding of activity rather
than capacity, the consequences of increased patient travel and human
resource implications). A follow up study (Gallivan and Utley, 2002b)
reinforced the view that there was potential for a large amount of capacity to
go unused. The reaction of the organisers to the latter work was to stop
responding to communications and the invoice for the work remains unpaid.
From the outside, this seemed consistent with an organisation in a state of
denial.
Although such work can have a very positive role in promoting effective policy
and avoiding pitfalls, it is recognised that the activity involved is essentially
‘devil's advocacy’. Such dispassionate critical review of proposed policy
changes can be an emotionally challenging process for an organisation to
submit itself to, particularly if it has already fully convinced itself of the
merits of an idea. It is recommended that new policy ideas should be subject
to independent, dispassionate devil's advocacy exercises. The availability
within the UK of groups with the relevant experience to undertake such
analysis is at present limited. This is not a role well-suited to consulting firms,
since there would be a potential reluctance to make recommendations that
are likely to be very unpopular with the client.
It is our view that this is an area where operational research has a significant
role to play but is underused within the UK health service. One of the key
roles of such analysis is to discard options that show unforeseen and
detrimental effects on estimated system performance. The ethos in much of
this work is that ‘while an idea that works in theory may not work in practice,
an idea that doesn't work in theory has very little chance of working in
practice’. The detrimental policy clash between the TC and Patient Choice
programmes, so easily predictable in 2002, and so clearly manifest in our
fieldwork, is stark evidence for this.
10.4 Conceptual implications of the research
Much of the thinking around organisational innovation will essentially be the
same as the broader business of managing change, and therefore the same
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rules, models and theories of change might be expected to apply (see review
in Iles and Sutherland, 2001). We will therefore not reiterate them here, but
focus instead on two of the major areas where important findings that
emerged from our study of TCs: the ways that local managers (1) plan and
(2) make decisions in such a turbulent environment.
Few would wish to challenge the contention that better, more rigorous, more
intelligent, more systematic planning over a less compressed time period,
with more stakeholder engagement and relationship building would indeed
have reduced the gap between plan and reality, and hence averted many of
the TCs’ ensuing problems. However, it still leaves a question as to how far
the TCs could have accurately predicted, and subsequently managed, for
example, their workload and activity levels, when their external milieu was
subject to so many unanticipated changes. ‘More and better planning’ is
therefore only part of the solution; the other part is how those involved can
get better at managing innovation and change in conditions of high
uncertainty and growing volatility and complexity.
10.4.1 Planning and complexity
One key point for future NHS innovation is that we cannot simply view and
adjudge the management of innovations like TCs from within the safe
confines of the mainstream ‘planning’ paradigm. We need instead to raise
questions about the paradigm itself – or at least to be aware that whatever
conclusions we draw will be shaped by this. For example, Fonseca writes:
Regardless of whether innovation is thought of as a ‘hard’ scientific and
technological process, a rational management process, or a ‘soft’ intuitive
human process, all these perspectives have in common the assumption that
innovation is a phenomenon that can be subjected to human control. It is taken
for granted that humans can purposefully design, in advance, the conditions
under which change will occur.
(Fonseca, 2002; p.3)
Even assuming the plan could have been more accurate, the question remains
as to whether this would have made the whole innovation process any more
controllable. Fonseca at least would say not:
I will argue that these processes… are fundamentally uncertain, making it
impossible to design in advance the settings that will produce innovations.
(ibid; p.9)
The TCs and those in a position to assist them could clearly have done more
and better local and strategic planning than they did, as evidenced by the
decision to cancel seven of the planned 24 independent sector TCs (Health
Services Journal, 2006). However it still needs to be recognised that there are
limits to the extent to which change and innovation can be planned, or at
least planned in detail and with a reasonable degree of accuracy. It is
interesting in itself that seven of our eight case study sites ‘got the numbers
wrong’, sometimes very wrong (and even the eighth is now having serious
difficulties in agreeing the size of its planned new-build phase two TC). Better
marketing and business analysis undoubtedly would have made a difference,
and those involved did acknowledge this, but the issues do seem to run
deeper than it being a simple case of bad management and poor planning.
Perhaps this is in the nature of complex processes, where no amount of
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planning and data gathering could have accurately predicted the numbers.
Like the weather, top-down planning approaches always carry the possibility
that the reality will not live up to the forecast. And to continue the weather
forecast metaphor, Quinn (1980) notes that ‘a good deal of corporate
planning is like a ritual rain dance. It has no effect on the weather that
follows, but those who engage in it think it does... Moreover, much of the
advice related to corporate planning is directed at improving the dancing, not
the weather’. As Beckhard (1997; pp.143-144) put it:
I have learned through experience and the experiences of those I have
consulted and taught that the correlation between a good plan and a good
outcome is, to say the least, unreliable. This helped me to understand … why
so many organisations’ strategic plans don’t end up in effective actions.
Beckhard’s point relating to the limits of planned change – fundamental in our
view – is that ‘getting the numbers wrong’ is not about bad planning or
sloppy thinking (although as our TCs show it can at least partly be) but about
the complex, unpredictable nature of innovation and change processes
themselves, that cannot be ignored in the hope that they become simpler and
more predictable. Instead the unpredictability must be proactively managed –
the notion of the management of innovation as the management of
uncertainty. (This was indeed recognised by many of the TC managers as
they strove to allow their TCs to evolve and survive in the changing
environment.) Kanter et al (1992; p.373) in similar vein wrote:
While the literature often portrays an organisation’s quest for change like a
brisk march along a well-marked path, those in the middle of change are more
likely to describe their journey as a laborious crawl towards an elusive,
flickering goal, with many wrong turns and missed opportunities along the way.
Only rarely does an organisation know exactly where it’s going, or how it
should get there.
Kanter (1983; 1989) also analysed hundreds of case studies and failed to find
any evidence for the success of rational planning models in most of them.
Greenhalgh et al (2005; p.80) cite this work as ‘some of the best empirical
evidence on how innovation arises in complex system’ Kanter et al (1992)
emphasise external causes such as those already noted in our cases: the lack
of data support from the wider NHS, but especially the politics of TCs trying
to manage upwards by ‘fudging’ activity forecasts to make them sufficiently
acceptable to the SHA that they would sign off the business case.
Those external, uncontrollable, and powerful forces are not to be
underestimated, and they are one reason why some researchers have
questioned the manageability of change at all.
(ibid; p.374).
External forces played their part in the TC planning debacle, but internal
managers must also bear some of the responsibility for the gross inflation of
activity forecasts we encountered in virtually all our case study sites. Those
making the case for TCs had to satisfy a tense web of internal and external
forces pulling them in various directions: the interests and concerns of key
players in both the internal and external milieus (Section 3), the often
mutually contradictory motivating forces from both central Government
(Section 2) and the host trust/TC (Section 4) and of course the subsequent
policy shifts (Section 5). This draws our attention to another neglected aspect
of research and practice: the politics of innovation. Clearly, the story of TCs is
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not just about planning or the lack of it, but about politics and complex
processes of dispute, negotiation and contestation.
Taking these factors into account Table 8 summarises these two contrasting
perspectives on the management of innovation: the mainstream planning
paradigm and the complex systems view.
The complex systems view of the planning and decision-making processes for
TCs is a long way from the traditional rational model with its roots in the
classical economic theory of the firm, and a broad set of assumptions that
goals, alternatives, risk, order of preference, and data are generally known
and clear. It is also quite distant from the bounded rationality model which
assumes decision makers have limitations that constrain rationality and
therefore may not consider all possible alternatives, settling instead for a
satisfactory not optimal solution. ‘An example is the difference between
searching a haystack to find the sharpest needle in it and searching the
haystack to find a needle sharp enough to sew with’ (March and Simon, 1958;
p.141). Like Lindblom’s description of what he calls ‘the science of muddling
through’ (Lindblom, 1959), in which decision makers make do with solutions
that are sufficiently satisfactory (that is, that ‘satisfice’), bounded rationality
allows for more open and dynamic planning, with decision makers changing
direction as new information and intelligence flow in. Clearly the TCs
displayed some elements of all of these models, especially the latter two. But
what we found, sometimes in precarious and uncertain situations of political
tensions and conflicting interests, had more the feel of the ‘garbage-can
model’ applied to change and innovation, (Cohen et al, 1972; see Figure 38).
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Table 8 Two contrasting perspectives on managing organisational innovation
Planning Complex systems
Assumptions rational, ordered, controllable, predictable, linear and sequential, and therefore manageable
disordered and messy, unforeseeable, unplannable, uncontrollable, flexible and emergent, and therefore barely manageable
Approach programmatic, rule-centred; building robust project management systems
pragmatic, human-centred, building ‘supportive social arrangements’ (Kanter, 1988)
Key focus structure, system and rules process and affiliation
Effectiveness better planning
tighter control and accountability
better preparation
intense network interaction, communication and relationship building
Key skills project management and organisational
political and networking
Sees itself professional and well-organised
entrepreneurial and opportunistic
Sees the other sloppy dogmatic
10.4.2 Sense-making and decision making
Pulling these various threads together, we – like others commenting more
broadly on New Labour’s approach to policymaking in the NHS (see for
example Greener, 2004b, who refers to a garbage can model which draws
freely on old ideas, giving them a new twist in a bid to secure successful
delivery) – began to see the story of TCs as more and more about sense-
making, decision-making, change-making and innovation in situations of high
uncertainty, ambiguity and volatility, where detailed planning-based models
of organisational change can be unnecessarily burdensome, unreliable or
plain useless. Explicitly recognising the tendency of intended strategies to
lead to unintended consequences, Balogun and Johnson (2005), studied the
social processes of interaction between middle managers (the equivalent of
many of our TC managers) as change recipients as they try to make sense of
a change intervention. In common with much contemporary organisational
change theory, they found that ‘managing change is less about directing and
controlling and more about facilitating recipient sense-making processes’
(p.1596).
Interestingly, the story of modern TCs is strongly reminiscent of the
‘irrational’ (Brunsson, 1982; Bryman, 1984), and ‘garbage can’, organised
anarchy and organic (Cohen et al, 1972) models of innovation and decision
processes found in the ‘classic’ organisation studies literature of the 1970s
and 1980s. The garbage can model was developed to explain the patterns of
decision making and innovation in organisations that experience extremely
high uncertainty. Cohen, March and Olson, the originators of the model,
called the highly uncertain conditions an ‘organised anarchy’ This is caused by
three characteristics:
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1 problematic preferences
- goals, problems, alternatives, and solutions are ill-defined; ambiguity
characterises each step of a decision or organisational change process
2 unclear, poorly understood technology (which we would widen out to all
systems and ask whether it might apply to all innovations)
- cause and effect relationships within the organisation are difficult to
identify; an explicit database that applies to decisions is not available
3 staff turnover
- in addition, staff are busy and only have limited time to allocate to any
one problem or task; participation in any given decision will be fluid
and limited.
Some of these conditions clearly applied to many, if not all, of the TCs we
have studied over the last three years (for example, the often ambiguous
nature of the relationship between a TC and its host trust or the high turnover
of senior staff in many of our case study sites), while others seem less
applicable, and there are some that need to be added to take account of the
peculiarities of the TC and, perhaps, health care innovation in general.
Nevertheless we believe that many local mangers who have been intimately
involved in the TC programme would recognise the garbage-can model.
The general point that does seem to apply here is that there is huge
looseness, randomness and disconnection in an organisational innovation
process like this, the outcome of which is determined by when, where and
how streams of problems, potential solutions, participants and choice
opportunities come together and match-up (or not). Hence, the decision
making that led to the TCs is like a large garbage can in which these streams
are constantly being mixed. When a problem, solution and participant happen
to connect at one point, a decision may be made and the problem may be
solved; but if the solution does not fit the problem, the problem may not be
solved.
Thus when viewing the organisation as a whole and considering its high level of
uncertainty, one sees problems arise that are not solved and solutions tried that
do not work. Organisation decisions are disorderly and not the result of a
logical step-by-step sequence. Events may be so ill defined and complex that
decisions, problems, and solutions act as independent events. When they
connect, some problems are solved, but many are not
(Daft, 1995; p.381).
The garbage can metaphor was chosen deliberately by these authors and is
not an attempt at humour but to challenge the rational model embraced by
(in their view) most change strategists and managers. And we suggest that
this applies in health care too:
The contents of a real garbage can consist of whatever people have tossed into
the can. A decision-making garbage can is much the same. The four streams –
choices, problems, participants, and solutions – flow toward the garbage can.
Whatever is in the can when a decision is needed contributes to that decision.
The garbage can model sees decision-making in organisations as chaotic:
solutions look for problems to solve, and decision makers make choices based
on the arbitrary mix of the four streams in the garbage can.
(Champoux, 1996; pp.403-404; see Figure 38)
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Figure 38 Garbage-can model
Source: Champoux, 1996
Most of the above theory focuses quite narrowly upon organisational decision
making, so a question that needs to be asked is whether it might also apply
to organisational innovation and service development processes in the wider
‘change’ sense, and does it apply more widely than TCs? It is beyond the
scope of this report to consider that question in detail.not least because one
would need to consider in some detail other models of problem solving,
decision-making and change found in the organisation studies literature,
including the rational model, bounded rationality model and ‘muddling
through’. However, as we have suggested there are many features of the TC
story that would fit the garbage can model. This is particularly evident when
one reviews the almost serendipitous confluence of local factors that led
(Sections 3 and 4) to the decisions to open the TCs. One can point easily to
the four streams of:
1 problems
- the need to be competitive, to improve throughput, to refurbish a
building, to tame the orthopaedic surgeons
2 choices
- a new ward? a larger day-unit? a change in outpatients? a TC? a deal
with the independent sector?
3 solutions
- acquire new funds to build a TC, send elective patients elsewhere,
import foreign surgical teams; introduce nurse practitioners
4 participants
- a sceptical chief executive replaced by an idealist; a nearby trust
deciding to send and then not to send patients, an SHA being able – or
not – to encourage patient flows to the TC.
However, the picture is not so straightforwardly just one of serendipitous
mixing of the contents of a bin. There was also a large measure of intelligent
ongoing sense-making and the very skilful use of the decision-making process
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to steer the innovation forward on whatever seemed the best available
course. We need therefore to consider not only how people arrive at decisions
or make plans, but also the follow-on question of how people might manage
an organisational innovation like a TC in conditions where there is this
random mix of influences, and where they lack the power or capacity to
analyse, prioritise and make rational choices via an explicit path. This
becomes an especially interesting question in a formal bureaucratic context
such as an NHS hierarchy that does not allow for, or would probably deny or
strongly disapprove of, this conception of reality. Behavioural theories have
portrayed organisational actors as the ‘puppets on a string,’ the helpless
plaything of social forces, the corks bobbing on a mighty sea – coping, trying
to keep their heads above water, surviving rather than managing. Yet we
found very little evidence of this among NHS managers dealing with an
organisational innovation whose very nature was a messy, unpredictable and
uncontrollable process where normal rational planning assumptions and
disciplines did not apply. Rather, our impression was of some quite artful
skippering of a vessel that was being tossed about by the ever changing
winds and currents. In other words, although the senior staff in TCs have
been buffeted by the constant changes, they (at least those that didn’t fall
overboard) have coped very well, many – thought not all – thereby helping
their TCs to survive the storm.
The way the TC innovation has been managed in the NHS had strong
elements of Lindblom’s (1959) description of ‘muddling through with a
purpose’, which is as much science as art. Just as anyone could learn to swim
so too, he said, could they develop the competence and ‘recipes’ to survive,
grasp opportunities, and ultimately reach dry land. Certainly the ‘science of
muddling through’ has been very much in evidence throughout our study of
TCs, but we prefer also to emphasise the power and potential of human
agency to overcome, even tame, these hostile conditions. What we have seen
in most of our sites is people ‘acting back,’ enacting their own environment in
the Weickian sense (Daft and Weick, 1984; Weick, 1995), all of this with an
almost heroic tenacity.
This view of innovation to which we are pointing does not reject the
description of complex, almost chaotic organisational reality, but reveals a
different response to it by the actors and participants. In the face of
adversity, they do not give up or even settle for muddling through or ‘hanging
on in.’ Rather, they reveal high levels of positive energy and resolve and
begin to work and pull together – almost in direct proportion to the height of
the mountain to be scaled or wave to be conquered. Positive organisational
scholarship (Cameron et al, 2003; see Section 10.4.3) would therefore give a
rather different ‘take’ on processes of organisational innovation from the
classic one of powerlessness and fallibility, one that is characterised by
resilience, virtuousness, care and commitment, loyalty, optimism, respect,
tenacity, even forgiveness. It focuses on the kinds of ‘transcendence’ and
‘positive spirals of flourishing’ (ibid; p.4) that approach the best of the human
condition.
In our case study TCs we have observed many of these qualities, and while it
does not always presuppose a good outcome, it does describe a positive side
to the process that needs to be included in our conception of the management
of innovation processes. The fact that this may happen in one TC and not
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another would lead us to consider some of the underlying dynamics in
virtuous and vicious cycles of innovation. The new theory implied by this view
might also explain the ‘ingredient’ that gets people out of the ‘garbage’ and
into a better place.
10.4.3 Conceptualising key success factors in health care
innovation processes
In order to identify some of the key success factors in innovation and change,
and to use these to evaluate the story to date of our TCs, we finally turn to
Greenhalgh et al (2005) who recently developed a model for analysing the
emergence and diffusion of organisation-level innovations (like TCs). The
model was developed by means of a systematic literature review on the
diffusion, spread and sustainability of innovations in the organisation and
delivery of health services, and was tested by its authors on four case
studies: integrated care pathways, GP fundholding, telemedicine and the
electronic health record. As the originators of the model caution: ‘we are
conscious that in presenting a… model of a complex reality, we risk
encouraging a formulaic, ‘checklist’ approach in which arrows connecting
different components are erroneously interpreted as simple causal
relationships that can be controlled and manipulated in a predictable way.
This, of course, is not the case’ (ibid; p.199). Rather ‘the model is intended
mainly as a memory aide for considering the different aspects of a complex
situation and their many interactions’ (Greenhalgh et al, 2004; p.594).
The authors pose nine questions with which to prompt reflections about the
diffusion and implementation of an organisational innovation (Greenhalgh et
al, 2005; p.200):
1 What were the features of the innovation as perceived by the intended
users (and also, separately, by top management and key decision
makers in the organisation)?
2 What were the features of the individual adopters and the
adoption/assimilation process?
3 What was the nature of communication and influence that drove the
diffusion/dissemination process?
4 What was the nature of the inner (organisational) context and how
conducive was this to the assimilation and implementation of innovations
in general, and this innovation in particular?
5 What was the nature of the outer (environmental) context and how did
this impact on the assimilation process?
6 Was the implementation and institutionalisation process (as opposed to
the initial adoption process) adequately planned, resourced and
managed?
7 What were the nature, capacity and activities of any external agencies?
8 What was the rate and extent of adoption/assimilation of the innovation,
and to what extent was it sustained and developed? If these are
considered as the dependent variables, to what extents do the answers
to questions 1 to 7 explain them?
It may seem odd to use these questions to attempt a general review of the
implementation of TCs as ‘an’ organisational innovation, given the wide
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variation we found among our sites. In doing so, however, we believe we can
draw out some wider insights into the management of organisational
innovations more generally. Both here and in Appendix 8 (which gives more
detail) we organise our responses to these questions (seven in total as we
subsume question 5 into question 4), which reflect the main components of
the model:
• as an organisational innovation a TC has a number of key attributes
which research suggests would point to a high adoption rate.
Importantly, TCs have a relative advantage which is readily apparent and
accepted to be high by virtually all users (in this context, GPs and PCTs
as well as end users) and which is compatible with the value system of
most NHS staff (that is, the provision of fast, reliable and efficient
treatment and improved care for patients). It also had a number of less
explicit positive attributes such as its usefulness as a vehicle to challenge
entrenched professional roles. This general consensus as to the inherent
value of the innovation may explain why – allied to a strong central
directive (see below) and their high potential for reinvention locally – TCs
appeared so rapidly and in greater numbers than originally anticipated.
While the concept of a TC is easy to understand and accept, it is
nonetheless a relatively complex innovation to implement, requiring
multi-professional and multi-disciplinary working from a variety of
individuals and teams (themselves operating within already complex
organisations), as well as wide ‘buy-in’ from a variety of external
stakeholders. And it always had the potential to stimulate resistance,
both from professionals who felt threatened by the changes it brought,
particularly when TCs became associated in many minds with a
perception that they were (by association with the private sector)
undermining some deeply-held NHS values.
• in terms of the adoption and assimilation of TCs – as we have discussed
in Sections 3 and 4 – the characteristics as well as the meaning of TCs to
the potential adopters(that is, the senior managers and clinicians
involved in the adoption decision process) were very varied. We would
define the adoption decisions as typically authoritative as opposed to
collective (in that individuals in organisations were told to adopt, rather
than everyone in a particular group deciding to adopt). However the
adoption processes tended to be ‘complex, iterative, organic and untidy’
rather than a single event (see Greenhalgh et al, 2005; pp.11-12). A
range of views among the potential adopters at each site (idealists,
opportunists, pragmatists and sceptics, as well as conflicting interests
around professional roles and status) reduced the likelihood of collective
adoption decisions within any given site. Financial (and to a lesser
extent) governance concerns have typified the concerns of adopters at all
stages of the assimilation of TCs into NHS organisations; these have
caused uncertainty and impacted on the ability of local leaders to
continuously adapt to the ever changing circumstances surrounding TCs.
• research evidence suggests that where innovations have been introduced
as formal developments (as in the case of TCs via the NHS Plan), their
diffusion tends to be via vertical dissemination networks (and is often
therefore planned strategically). Certainly, NHS TCs did spread mainly
via vertical networks but later their spread was also influenced by ‘lateral’
connections, particularly when NHS trusts saw TCs as an opportunity to
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achieve any number of local objectives and reacted accordingly. Most
often, trust clinicians and senior managers – including chief executive
officers - were the ‘opinion leaders’ (although often not all clinicians were
supportive and some were hostile to the innovation).
• the inner context (referred to in Section 3 as the internal milieu) was
such that virtually all TCs were introduced into large organisations with
high degrees of specialisation, functional differentiation and
professionalisation but typically with few slack resources and limited
ability to manage a long-term organisational change process and to
evaluate it over time. The research evidence suggests that such
organisations will assimilate innovations more readily, although such
characteristics together account for only 15 per cent of the variation in
‘innovativeness’ between comparable organisations (Greenhalgh et al,
2005; pp.11-12). Following the observation made earlier in this section
(based on Pressman and Wildavsky’s 1973 research) the early planning
and building phases of TCs were typified by strong project management
(utilising pre-existing strengths of clinical expertise and capital projects
management) but this close project management typically ebbed away
after the opening of the facilities. The complex, shifting management
agenda, often entailing conflicting goals as well as increasing competition
for management time, reduced the organisations’ absorptive capacity.
Although the basic premise of separating elective and emergency care
fits very well with prevailing views as to the future configuration of acute
services, the training and other system-wide implications of TCs were
often not thought through by adopting organisations at an early enough
stage.
• the outer context (Section 3’s ‘external milieu’) was characterised by a
very strong central, top-down drive to encourage (at times, insist upon)
the adoption and spread of TCs (reinforced by national performance
targets), all of which encouraged the early uptake of this innovation. This
contrasts with some other recent innovations in health care; for example,
integrated care pathways which initially arose peripherally and were
spread informally via the professional networks of clinician enthusiasts
(Greenhalgh et al, 2005; p.203). However the viability of at least some
TCs has been undermined by apparently conflicting national policies,
some of which (the expansion of private sector provision for example)
have been controversial both within and outside the NHS.
• features of the implementation and institutionalisation process included
significant recruitment and/or training in the early stages and strong
reliance on influential enthusiasts and supporters (particularly among
clinicians). Middle managers in the ‘host’ trusts were sometimes not well
disposed to what they saw as the freedoms and opportunities afforded to
their contemporaries in the TCs. However they also saw the benefits of
the innovation in helping them to meet targets such as waiting times and
patient throughput, and in challenging entrenched clinical traditions.
Although some TCs have established outcomes measurement as a core
activity – and all conduct patient satisfaction surveys – there is little
strategic assessment of their impact on wider health care systems (and
most have poor internal IT systems). This is important as research
suggests that accurate and timely information (through efficient data
collection and review systems) on the impact of the implementation
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increases the chance of successful routinisation (Greenhalgh et al, 2005;
p.15).
• finally, as far as the role of external agencies was concerned, although
significant funding was made available for capital projects, central
support for addressing the challenges of implementation was more mixed
and piecemeal, and fell away to a significant extent after the demise of
the Modernisation Agency. And as our analysis showed, often the
meanings attached to TCs by external agents (the Modernisation Agency,
Department of Health, SHAs etc) were at odds with those attached by TC
managers and staff.
So what does this overview of TCs as an organisational innovation tell us
about how such innovations might be managed in the future? Firstly, that
even a combination of (a) high relative advantage (even when it is widely
acknowledged), (b) close compatibility with the values, norms and perceived
needs of adopters and (c) a high potential to adapt, refine and modify an
innovation is insufficient to guarantee the successful implementation and
spread of a complex organisational innovation. Rather, our findings seem to
confirm that it is the interaction between an innovation, its intended adopters
and its context that determines the adoption rate and the success or
otherwise of its local implementation.
Secondly, although the early diffusion of organisational innovations can be
accelerated by a strong top-down policy directive (and given further weight
by means of capital funding, central facilitation and powerful local champions
in the form of senior clinicians and trust chief executives), successful
implementation of such a directive requires consistent strategic and front-line
change management skills which are often in short supply in the NHS. Where
the organisation’s existing knowledge and skills base is insufficient, then the
use of external change agents to support implementation requires a common
language and values system, and shared meanings. As we have argued in
this report, and as Greenhalgh et al (2005; p.9) reinforce, ‘if the meaning
attached to the innovation by individual adopters is congruent with the
meaning attached by top management, service users and other stakeholders,
assimilation is more likely’. This was not always the case with, say, the
Modernisation Agency. External facilitation of networking and collaboration to
support adopters should explicitly acknowledge and address the not only
common implementation challenges but also the pervasive contests of
meaning.
Thirdly, although many of the typical structural characteristics of a large
acute hospital (with its specialisation and functional differentiation) should
increase the likelihood of the adoption of organisational innovations, the
typically limited – or absent – ‘slack resources’ in NHS trusts reduces the
receptivity and hence the assimilation of the innovation. This lack of internal
resources again points to the potentially important supplementary role of
external networks and practical support.
Fourthly, conflicting parallel policy initiatives and resulting uncertainty can
militate against the ability of those leading implementation at the local level
to respond as adaptively as they would like (especially if such initiatives are
controversial and have mixed support).
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Fifthly, implementing complex organisational innovations that cut across pre-
existing organisational boundaries (both at the local and regional level)
requires a greater focus on the issue of ‘connection’ both vertically and
horizontally – particularly if the NHS is to operate as an ‘innovation system’
rather than a loose collection of fragments. Such connectivity will be at
increased risk if the Department of Health succeeds in its intention to
introduce a policy environment that is based less on top-down directives and
more on patient views and local incentives (see Section 10.3.1; Figure 35).
Finally, our analysis of TCs suggests that both the ‘planning’ and ‘complex
system’ perspectives (as summarised in Table 8) have weaknesses and
omissions but it is in the discrepancies and differences between the two that
we may find some important lessons for managing organisational innovations
(as others have previously discussed in much more detail than we are able to
do here). For example, Poole and Van de Ven (2004; p.395) point out that,
while it would be a mistake to complicate our thinking simply for the sake of
complexity, ‘it is through the dialectic between simplification and
complexification [sic] that our understanding of change and innovation
processes will ultimately advance’. Seo et al (2004; pp.101-2) argue that
‘dualities’ (polar opposites that work against one another) can help to ‘draw a
realistic picture of planned organisational change, particularly its complex and
dynamic nature... [Acknowledging and valuing dualities and tensions] may
increase practitioners’ awareness of various hidden but essential dynamics
associated with organisational change and its consequences’. In the case of
TCs, one limitation of the ‘rational, linear planning model’ of innovation is
especially unsuited to ‘volatile environments’ (Augustine et al, 2005) that are
not stable, known or consistent, not least because they were never designed
for change but for maintaining order. Many in the NHS would argue that they
are experiencing a more ‘volatile environment’ than ever before, with so
many structural and leadership changes, and so many unknowns, such as the
involvement of the private sector and the introduction of Patient Choice. And
any innovation itself adds to this ‘volatility’. If this is the case, the rational
model will always be found wanting, no matter how skilled people are in its
use. Equally, the second, complex perspective is on its own unlikely to be
effective, leading to missed targets, drift and growing resentment among
other stakeholders about the lack of knowledge, co-ordination and an overall
systems view. In a similar vein to our earlier point about design rules,
Eisenhardt and Sull (2001, as cited in Balogun and Johnson, 2005; p.1596)
argue that:
In highly dynamic or complex conditions senior managers cannot be expected to
‘know’ all that is happening. Top managers should therefore focus on the
development of simple rules, for example regarding expected outcomes or
boundary conditions, which set the limits within which other organisational
actors have to interpret what makes sense and what should be done. In
situations of change, too, actors similarly have to translate top-down intent in
the context of their own realities. This suggests that ‘managing’ change may be
more to do with senior management striving to deliver clarity of purpose,
expected outcomes and boundary conditions, and a shared understanding of
these, rather than trying to manage the detail.
This also brings us back to our earlier point that ‘implementation cannot be
divorced from policy’, with the implication that organisational innovation
needs a judicious mix of the planning and complexity views of policy making
and implementation. One needs plans and controls (more than we found in
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our study) but – and this is the important point – only for those things that
you can plan and control. But one also needs processes and skills that can
deal with all the emergent, unpredictable aspects of the innovation
implementation process (which again were not greatly in evidence in our
sites); what we might call ‘agile innovation.’ We would suggest that the NHS
needs if anything to look much more closely at the complex systems
perspective for it begins to reveal the relatively unexplored aspects to
organisational innovation in the NHS and also seems increasingly well-suited
to the new and emerging policy context with its emphasis, so characteristic of
complex systems, upon self-managing and self-improving.
10.5 Practice implications of the research
10.5.1 For policymakers
1 Top-down target-led central innovations will inevitably be re-crafted at
the local level to suit local needs and build on existing initiatives; they
need therefore to retain appropriate flexibility (headroom) if they are to
be crafted while still successfully fulfilling their core objectives.
2 Policymakers should try to facilitate local innovation using ‘design-
principles’ that acknowledge the likelihood that rational planning of
innovations will be limited in both its feasibility and its applicability in the
‘volatile environment’ of NHS management.
3 There should be more rigorous evaluation of innovative policies while
they are on the drawing board, and where this reveals strong evidence –
for example from modelling techniques – that problems will arise from
the widespread implementation of an innovation, caution should be
exercised.
4 Assessments of the likely impact of new policies on those that are
already working their way through the system should be undertaken
before a new policy is introduced nationally.
5 Even where an organisational innovation has all the attributes of likely
success (for example it is widely acknowledged to have high relative
advantage; it is apparently compatible with the values, norms and
perceived needs of those who are expected to adopt it; and it has the
potential to be adapted to a range of local requirements) there is no
guarantee that it will work. It is also necessary to explore very carefully
the potential interaction between the innovation, its intended adopters
and its context when assessing the likelihood of successful
implementation.
6 Specific training may be required among managers at all levels of the
NHS, as successful implementation of organisation-wide innovations
require a high level of both strategic and front-line change management
skills, which are often in short supply.
7 Where the organisations’ existing knowledge and skills base is
insufficient, then the use of external change agents to support
implementation may be required but is unlikely to succeed unless there
is a common language and values system, and shared meanings between
the policymakers, the facilitators and the front-line innovators.
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10.5.2 For change leaders and management practitioners
Service innovation is a social and organisational process, which means that
the management of innovation is predominantly an issue of managing the
social and organisational factors associated with that process. Below we have
identified and detailed – under seven headings – 74 such factors that arose in
our research; these are presented in the form of ‘design principles’ (Romme,
2003; Van Aken, 2004, 2005a, 2005b) for service delivery innovation (with
cross-references back to the main text). The points in 10.5.1 also apply here,
particularly the fifth.
Dealing with complexity, non-linearity and unpredictability
As we have discovered during the course of this research, the innovation
process is characterised by high levels of complexity, ambiguity, uncertainty
and unpredictability (see in particular Section 6 and Section 10.2), and no
amount of planning and attempted control is ever likely to change or
compensate for that. Therefore it is better, we believe, to take steps that
allow change practitioners to work ‘with’ these forces rather than infinitely
wrestling to tame and get on top of them. The management of complexity (as
opposed to the resolution of complexity) is thus core to the process and
practice of innovation. Therefore the following points are recommended:
1 Keep the portfolio of innovation initiatives to a manageable size; do not
try to chase everything that appears (as, for example, did Site C);
‘informed opportunism’ is about making felicitous choices not chasing
every management fad or fashion that passes by.
2 Ensure that there is a concise, evidenced and cost/benefits-based
business case for the innovation with a clear vision, aims, finance
forecasts and objectives (especially around elements such as capacity
and demand estimates, skill-mix, case-mix and volume projections, key
performance indicators and competitor analysis). Remember that three
TCs in our study ‘failed’ because there were simply not enough patients –
the business case had been built on hugely over-optimistic demand
assumptions. Also be clear and upfront in the case about motives,
aspirations and intentions. This is your ‘workable blueprint’ (Van de Ven
et al, 1999) or ‘frozen ambitions’ (Van der Knaap, 2006). Being a
relatively fixed point it will provide the North Star for the innovation
journey – especially helpful when (inevitably) you find yourselves blown
off-course or in stormy waters. Business and strategic planning of this
kind needs to take precedence over detailed operational planning, which
can itself become an increasing burden and source of anxiety when the
‘reality’ begins to diverge (as it surely will) from the plan.
3 To address the above, roomy, adaptive (as opposed to detailed, hard-
wired) strategic plans are needed – directional rather than detailed but
addressing all the key strategic ‘choice points’ for innovators, such as (for
example in the case of TCs): single specialty or mixed specialty; how far
the innovation is about ‘improved efficiency’ or ‘improved experience’;
how clear and complete the separation will be between emergency and
routine elective treatment; the choice between day case or short stay;
the extent to which the TC will operate as an autonomous, stand-alone,
ring-fenced ‘hospital within a hospital’ or as an ‘extension’ of the main
hospital (Section 6.5.4); whether there should be diagnosis and
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treatment (‘one stop shop’) or one or the other; and whether the TC
should be virtual or real
4 In this kind of unpredictable innovation environment, ‘preparation’ is as
or more important than ‘planning’ – people often plan because they are
not properly equipped or prepared (in terms of skills, resources, shared
vision, team effectiveness, motivation and direction); or put the other
way round, the more prepared (‘match fit’) you and your team are the
less you may need to plan in huge amounts of detail.
5 Do wider horizon scanning to pick up any distant clouds that might put
future projections at risk, for example Patient Choice and Payment by
Results (Sections 6.2.2 and 6.2.3), changes to GP commissioning,
involvement of the independent sector (Section 6.2.1), mergers and
reorganisations, closures (see Section 5 for further examples and their
impact).
6 Flexible ‘physical’ design to accommodate future innovation in both
equipment and procedures (especially when there is the danger of
‘building the wrong thing in haste’ (see Section 2.3). In the context of
the ‘pressurised planning’ (Section 6.1.2) that surrounded TCs, this
concept of flexible design needs to go beyond physical buildings to
embrace many other aspects of the innovation process, including the
organisational and management dimensions (see Site E, Section 6.4.2,
for an example of effective flexibility).
7 Avoid drowning in detail by focusing on key aspects of care, core
measures and ‘dashboards’, and measuring only the ‘meaningful stuff’.
8 Encourage small-scale innovation experiments and develop and test
various prototype solutions before spreading system-wide (it is worth
noting that, in this vein, the Department of Health suggested leasing a
facility to see how it works out but we are not aware of anyone actually
having done that).
9 Build in flexible contingencies and formulate and rehearse multiple and
explicit ‘imagine if’ scenarios.
10 Try to develop, dry-run and test performance measurement, scheduling
and planned booking, information and other systems in advance of ‘going
live’ – the notion of carrying out test flights for fledgling or early
innovations.
11 Do not concentrate on designing and planning to the detriment of
implementation and ‘trying out by doing’ – making ‘test flights’ as
opposed to trying to work it all out ‘from the ground’. Building to pilot
and test, learning faster by failing early and giving permission to explore
new behaviours are likely to be more productive than trying to theorise
about and plan for everything in advance (Coughlan, Fulton Suri and
Canales, 2007). To some extent this runs counter to what the
Modernisation Agency was advocating in the way of TCs having detailed
operational plans. See quotation from Site B in section 4.1.2 for an
example of effective enactment and enabling activity.
12 Improvisation and improvisational behaviour warrant a special mention
in this practice category. There is growing evidence of extensive use and
acceptance of improvisation in the management of change and
innovation, not because it is fashionable or even necessarily creative but
because it is the only way of coping with complexity and fast change, and
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the flexible behaviour and spontaneous decision-making these require
(Leybourne, 2007; Chelariu et al, 2002; Crossan, 1997). Improvisation
activity therefore needs to be built in to the innovation process and also
developed as a core competency by those involved.
13 Finally it is important not to give the impression that absolutely
everything associated with the innovation process is unfathomable,
unpredictable and unplannable. Much of it is but a lot of it is not.
Currently a good deal is not being (fore) ‘seen’ simply because the
planning ‘instruments’ being used are insufficiently sensitive or accurate
for this to happen. In contrast to the rather crude intuitive planning and
scheduling methods in current use in TCs, our research shows that there
is huge potential for even fairly conventional mathematical modelling and
analytical tools to be deployed so as to reveal the many things that can
actually be analysed and predicted, and hence to narrow the gap
between what is currently known and could be known (for example
predicting capacity requirements, optimising patient flows and bed
capacity, deciding whether a TC will improve the efficiency with which
capacity is utilised within the local health community, managing
variability - see Sections 8 and 9). Practitioners therefore need to
differentiate between what is genuinely unknown and unknowable, and
that which could be known if they knew how and where to look.
Creating ‘enabling’ structures and systems
Structure is the ‘skeleton’ for the innovation process, its purpose being to
connect all the various roles together and to provide the necessary functional
coordination between them. Structure does provide a mechanism of control
and accountability during innovation and change but its main purpose is to
enable new roles, behaviours, processes and patterns of behaviour to emerge,
develop and ultimately intertwine and work as a system.
1 Establish a core multidisciplinary, preferably multilevel, innovation team
(a ‘core of like minded people’ – Site B, Section 3.1) and take sufficient
time to develop a shared aspiration and unity of purpose between its
members. One of the first activities should be to vigorously challenge the
initial claims and assumptions contained in the business plan which often
turn out to be well wide of the actual mark (Section 6.1).
2 Clearly define all key roles and line responsibilities of those involved in
the innovation process.
3 Establish complete transparency in staff recruitment and avoid
favouritism (Section 6.5.1); try to anticipate where staff shortages are
likely to be and where alternative arrangements may need to be put in
place (Section 7.2.3).
4 Clarify and agree gradings and new terms and conditions sooner rather
than later – get the ‘structural basics’ sorted out.
5 Establish robust project management processes but avoid the heavy
hand of old, ‘soviet-style’ administrative structures that take away the
energy, enthusiasm and resilience of those involved, and bring about
premature ‘death by project management’.
6 Organise around clear and agreed treatment protocols and care pathways
(see Section 7.2.2 for the details and challenges of doing this) – in other
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words do not organise in the abstract but tie structures in to clinical
processes.
7 Be aware of the need to create new or extended roles that cross
traditional boundaries, for example schedulers, extended roles for
therapists (Site B, Section 4.1.2); advanced nurse practitioner (Section
7.2.3), new assistant practitioner and anaesthetic practitioner roles
(Section 7.2.2); constantly challenge the logic of traditional structures,
seeking not just alterations but real alternatives (Section 7.3).
8 Create ‘slack’ for people to grow into these new roles and don’t accept
the view of innovation as ‘overtime work’ on top of normal duties which
can only be sustained for a limited time (see Site G, Section 3.1).
9 Establish linking and liaising roles (for example clinician managers,
service innovation team) – vertical, horizontal and diagonal!
10 Start early to build a marketing and communications strategy (Section
6.4.3), structure and process (see Section 3.2 for importance of
‘meticulous communication’).
11 Endeavour to maintain continuity in key staff positions by recognising
and rewarding accordingly (see Section 6.5.2).
12 Clear targets (key performance indicators) and incentives for
performance (for example waits and length of stay), safety and
experience.
13 Attend to and put in place clinical and governance arrangements well in
advance of opening.
14 Agree – and enforce – strict protocols for patient selection, and inform all
relevant parties what these are.
15 Ensure adequate levels of IT and information support are available from
the outset, especially in relation to booking systems (Section 6.5.3).
Navigating the politics of innovation and securing stakeholder
engagement
NHS service delivery innovation requires collaboration between multiple
professional and occupational groups and thus involves complex political
challenges in ‘uniting them in thought’ and getting them lined up behind the
TC (Section 6.5). Innovation is constantly threatened by antagonistic
relations between key players (Section 6.3.2) and constant attention
therefore needs to be given to building and maintaining the (highly fragile)
‘negotiated order’ (Section 3.4).
1 Engage, inform and involve the senior executive team, board and (where
applicable) members council from the outset – and keep them involved.
2 Clarify relationships and interdependencies between units, departments
and the wider organisation (especially ‘freedoms’ around the TC/trust
relationship; Section 6.5.4); resist the natural drift into adversarial
relationships, derogatory stereotypes and damaging ‘them and us’/win-
lose dynamics.
3 Trust needs a special mention in this category: this research has shown
repeatedly that once trust has broken down or been violated (especially
between a hospital trust and its community ‘partners’) the success of the
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innovation will be in serious jeopardy (for example Site F, Section 6.4.1;
Sites C and G, Section 6.4.2).
4 Align unit innovation strategy to wider organisational and SHA strategies
– for example so that it fits in with ‘local development plans’ Section
3.2); at the same time there should be ‘no surprises’ for any of the key
stakeholders.
5 Address the ‘what’s in it for me’ (called the ‘motivators’ in this report) for
all key groups crafting and framing the ‘case’ to suit and connect with
local agendas and ideals and the ‘things that need fixing’ (efficiency and
quality concerns; hospital regeneration (Section 3.1), improved working
life – things that managers, clinicians and patients would see as the
benefits or ‘relative advantages’); for example tapping in to the ‘things
that worry and attract doctors’ (Section 3.1). Different frames will be
required for opportunists, idealists, pragmatists and sceptics (Section
3.4) and for managers and clinicians; see section 4 in particular for
detailed examples of the different motives at play; these divide roughly
into:
a quantity, performance, efficiency, revenue, resources (especially
appealing to managers but the latter also to clinicians)
b quality, experience (especially appealing to clinicians)
c kudos (especially appealing to senior figures).
6 Incentives and rewards are still one of the most powerful ways of getting
innovation adoption; these can be financial or non-financial (Section
7.2.3).
7 Find local innovation champions and leaders and empower them to take
responsibility for getting their particular professional colleagues on board
(Section 7.1) – the ‘like recruits like’ homophily principle
8 Listen to the sceptics; they are often voicing the concerns of the silent
majority.
9 Deal with opponents and adversaries by including them in the innovation
process; leaving them out is only likely to increase the bickering, hostility
or opposition (see Site E, Section 3.2).
10 Develop new care pathways and models of care with those who are
supposed to be adopting and following them and avoid imposition.
11 Look for ‘catalytic’ and ‘piggy-back’ events for promoting the innovation
and winning the support from internal and external stakeholders.
Building the innovation network
Innovations like a new TC are as much a ‘social’ community and network-
building enterprise as a ‘technical’ project, depending for their outcome on
the assistance and support of a wide range and number of interested third
parties. It is essential to ensure in the main that these are ‘helping hands’ not
‘hindering hands’.
1 Don’t try to foist your TC on the wider health community: make dialogue
and dense face-to-face interaction an external as well as internal feature
of the innovation process.
2 Build and nurture close and constructive relationships with local health
community partners, including GPs (innovation is about building
relationships, especially trust).
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3 Also build direct links with community groups through meetings and
consultation exercises, and involve representatives on key meetings.
4 Search out possible strategic partnerships and alliances (including
independent sector).
5 Link with specialist external groups and make use of the expertise,
protection, and networking capacity of agencies like the Department of
Health, the Modernisation Agency, the NHS Insitute for Innovation and
Improvement (Section 2.3.1) or NHS Elect (Section 5.5).
Creating a learning process
Innovation and change processes are also learning processes – thus ‘no
learning no change’. ‘Learning’ in this regard needs to address the harder
knowledge and skills issues as well as the softer awareness-raising and
developmental issues.
1 Treat the innovation as an ongoing individual and group learning and
development opportunity (Section 7.2.4).
2 Create from day one a parallel formative/developmental ‘evaluation for
learning’ stream alongside the innovation process, so that events and
experiences can be learned from and a continuous cycle of
reflection/improvement/refinement established.
3 Use this and other opportunities to raise process awareness and
challenge conventional assumptions about the nature of innovation and
change (for example whether patients – and clinicians! (Section 6.5.1) –
would be prepared to travel to a different provider for treatment –
Section 6.4.3).
4 Encourage internal and external (action) research of aspects of the
innovation process.
5 Be aware and ‘design for’ possible unintended consequences or ‘spin offs’
from the innovation (positive and negative – for example resentment and
hostility from the wider trust; Section 3.1).
6 Identify any skills gaps early on and address these by way of dedicated
training and development programmes. Such programmes will cover
skills training but also behavioural, attitudinal and mindset issues (cf.
Site C, Sections 4.1.2 and 4.1.3).
7 Treat setbacks as opportunities for learning (not blame).
8 Hold regular all-staff review days and away days.
9 Seek opportunities to embed a ‘culture of questioning’ within the
innovation process.
10 Encourage members of the core team to attend specialist workshops and
conferences (for example Ambicentres International) and visit other sites
(knowledge exploration and exploitation is crucial to the innovation
process).
11 Look for and take advantage of any free expertise in the system, for
example the Modernisation Agency (Section 2.3.1) and its successor, the
NHS Institute for Innovation and Improvement
12 Obtain regular feedback on improvements (or not) in both patient and
staff experience; establish a network of trusted informants.
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13 Conduct a summative (‘how did we do’/‘learning for judgement’)
evaluation at discreet stages of or at the end of the project to capture the
lessons retrospectively and build them into a set of design principles for
future innovation (‘if you want to achieve outcome Y in situation S,
something like X might help’).
14 Improvisation is also a powerful learning mechanism (see Section 10.5.2
(point 12) on ‘learning to improvise, improvising to learn’), as is
prototyping and pilot testing.
Changing behaviour and culture
Innovation is about changing mindsets and behaviours so that people ‘think
and do’ in different ways. As our research confirmed it is very easy for an
innovation attempt to become mired in the traditional ‘way we do things
around here’ and to end up more of a replication than an innovation. It is said
that culture is like ‘gravity’: you only feel it when you try to jump six feet in
the air. Clearly all the sites experienced these normalising or gravitational
effects of the trust culture, although some were ultimately more successful in
getting in to orbit than were others (Section 7.3).
1 Try to develop an awareness of the inhibiting ‘brake effects’ of existing
cultural practices and traditional mindsets; constantly challenge the
common sense in which culture meanings are wrapped; approach the
culture more as an outsider than a native; because in the case of culture
‘the fish is the last to see the water’. Use outsiders, including patients
and carers, to reflect back how they see and experience the culture.
2 Focus on building a unique and distinct identity for the TC that patients
and staff can relate to and value, and an image that ‘badges’ and brands
the ‘product’ and establishes its unique selling point and attracts
attention and support in the wider field. Decide whether to call your TC a
TC or not (labels do matter), and discuss whether staff loyalties should
be primarily to the TC or to the wider trust.
3 Also concentrate on developing a strong and supportive ethic or ‘ethos’
around the TC (for example Site G, Section 3.2), for example stressing
openness, honesty, treating staff and patients with dignity and respect;
striving for excellence, listening and encouraging feedback and so on
(Section 3.1); or giving treatment based on the ‘wellness’ rather than
‘illness’ model (Section 3.1), and guaranteeing continuity of care (Section
7.2.3).
4 Hold opening ceremonies and official launch events as a symbol of the
importance being attached to the innovation.
5 Award other symbols of recognition for service excellence, for example
TC nurse of the year award, chair’s award.
6 Value and reward ‘thinking outside the box’ and resist attempts to
normalise and reincorporate the innovation back into the normal frame of
‘the way we do things around here’.
7 Concentrate on building a strong, team-based, entrepreneurial ‘just go
do it’ culture or ‘can do mentality’ like that which was evident in a
number of TCs (Section 7.2.4).
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8 Value and reward good ‘citizenship’ behaviours within the TC (that is,
support activities that go beyond the normal call of duty) for example
Site F clinical manager, Section 7.3.
9 Reward and celebrate achievement.
Leadership
• Look for emergent and rising leaders rather than the ‘usual suspects’
(‘use the same old horses and what you get is the same old glue’).
• Adopt as far as possible a ‘help it happen’ as opposed to ‘make it happen’
or ‘let it happen’ approach (Section 10.1; Figure 35, Section 10.3.1).
• Move from a rule-based to an incentive-based form of leadership: ‘pull’
rather than ‘push’ leadership.
• Ensure leaders are aware of the importance of ‘framing to fit’ – telling the
‘innovation story’ in a way that appeals to and resonates with the values,
sentiments and goals of key audiences (Section 10.3.1).
• Ensure that participation and inclusion remain the watchwords of this
form of leadership, avoiding the natural temptation to ‘keep the cards to
the chest’ and to exclude external parties in particular from decision-
making (Section 3.2).
• Establish clinical leaders as the ‘primus inter pares’ for the innovation
initiative.
• Establish a leadership system or process that is based on professional
leadership lines.
10.6 Implications for research
In this final section we address the implications of our study for future
research, noting as a starting point that ‘the empirical literature on the
implementation of service innovations in health care is currently extremely
sparse’ (Greenhalgh et al, 2005; p.18).
1 Research is needed on the appropriate balance between centrally-
generated innovations and those that are generated locally and
disseminated laterally. The intended shift in the policy environment from
the former to the latter will provide an interesting natural experiment.
Greenhalgh et al (2005; p.227) have identified a related research gap on
behalf of the SDO programme, namely: ‘What are the harmful effects of
an external ‘push’ (such as a policy directive or incentive) for a particular
innovation when the system is not ready? What are the characteristics of
external pushes that tend to be more successful in promoting the
assimilation and implementation of innovations by health service
organisations?’
2 Work is needed to help develop and evaluate the concept and use of
‘design principles’ in facilitating successful innovation. For example,
within the new NHS policy context it might be possible to work with SHAs
(perhaps using an action research or formative evaluation design) to
explore the place of design principles for organisational innovation at the
local level.
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3 The nature and place of positive organisational scholarship (see Section
10.3.2 on ‘rules-based system’) should be explored as a means of
fostering a more receptive environment for organisational innovation.
4 We need to understand more about how middle managers, such as the
managers of the TCs and front-line NHS staff in general – given their
central role in innovation – make sense of and therefore contribute to
change outcomes in different change contexts. This recommendation
builds on the conclusions of Balogun and Johnson (2005). Relatedly,
more work is needed to understand how the inevitable contests of
meaning in multi-level and multidisciplinary organisations can be more
successfully reconciled.
5 What are the sources of evidence that decision makers draw upon when
making the decision to innovate, and how are these played out in the
negotiations and debates that precede the decision and subsequently
shape its journey? In particular, how do political and power relations and
organisational roles impact on this process? This question resonates with
the conclusions of a recent study funded by the NHS South East Research
and Development Division, exploring the use of knowledge sources by
communities of practice formulating care packages for the elderly
(Gabbay et al, 2003).
6 A study is needed to explore the barriers and opportunities for change
based on the findings of theoretical planning exercises and operational
research studies. In particular what might better facilitate the influence
of such evidence on service delivery and organisation within the NHS?
Related to this, a study is needed that explores the ways in which
modellers and operational researchers might dispel the ‘Cassandra
complex’ that currently affects much of their work. Of relevance to both
of these questions is the work of MASHNET – the Network in Healthcare
Modelling and Simulation (see www.mashnet.org) – funded by the
Engineering and Physical Sciences Research Council. The results of an
SDO-funded project looking at how operational research can facilitate the
implementation of stepped care for common mental health problems is
also of interest (see SDO/109/2005 at www.sdo.lshtm.ac.uk).
7 A highly relevant methodological question, which we have struggled with
in a number of other organisational studies in the NHS, is how
researchers can best handle the problem of studying an organisational
entity that is subject to a range of (sometimes incompatible) meanings
held by key players. This problem is heightened when the research
sponsors subscribe to just one of those conflicting perceptions or expect
researchers to measure success against targets and criteria defined by
policymakers but which are being imperceptibly, perhaps deceptively,
transformed by front line managers and staff. This question arose from
Pope, Le May and Gabbay (2006). See Appendix 9 for more details of this
paper.
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Appendices
Appendix 1 Information sheet for participants
INFORMATION SHEET
Research study – Treatment Centres
University College London and University of Southampton
More than fifty NHS and Treatment Centres (TCs) will be established within the NHS
over the next five years. The Centres are a new, innovative way of providing health care
to thousands of patients who need specific diagnostic services and/or treatment (for
example, those requiring hip or knee replacements or those with cataracts). The Centres
are being specifically designed to ensure that such patients will be seen with minimum
delay and avoid long in-patient hospital stays.
This independent, three year research evaluation of TCs is funded by the NHS Service
Delivery and Organisation (SDO) Research & Development programme. The research
will be undertaken by a team led by Professor Paul Bate from University College
London’s Medical School in collaboration with colleagues at the Clinical Operational
Research Unit and the University of Southampton. This research – guided by an
advisory group that will include patient representatives as well as clinicians and
managers – will examine whether TCs are successful in increasing the numbers of
patients who are diagnosed and treated within their local health communities. The
research will also explore the ways in which some of these Centres (opening in 2002/03)
are organised and managed with the aim of learning important lessons that can then be
shared with other Centres which are due to open later (in 2004/05).
Purpose of the study
The purpose of this research project is to describe and evaluate a small sample of NHS TCs,
following them through from their initial conception and development to full implementation.
This process will entail not only the generation of findings but also the regular sharing and
validation of these findings with participants. This study will examine the process of change
as well as the impact of TCs on the organisation of patient care. An integral part of this
process will be feedback of the emerging findings to those involved – including users as well
as clinicians, managers and policymakers – which will allow the findings to be jointly
analysed. This approach will aim to ensure that the lessons will be rolled out as the rest of the
NHS adopts this model of service provision.
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Methods and Procedures
Use of mathematical modelling to calculate how many and which patients will be treated, and
how best to organise services
Face to face interviews with health care staff and patients to find out how they view various
aspects of the operation and degree of success of the TCs over the three year period
Observation of health care processes in the centres
Postal questionnaires sent to health care staff to further explore how the TCs are being
organised and managed.
Topics of research interest
Reviews of the change management and innovation literatures and previous research by the
study team have identified a number of critical success factors relating to initiatives like the
development of TCs. Our interview topic guides will therefore be structured around the
following themes: organisation structure; mission and strategy; skills and development;
quality and governance issues; human resource aspects; information systems; communication;
change models; measurement; motivation, commitment and reward, teams and team working;
leadership and decision making; changes in cultural norms; changes in working practices and
patterns; relationship with key constituents; and identity, values, ethos, ideology and
commitments.
Benefits
Benefits to participating sites – and to the NHS TC programme – in general include:
An in-depth description and analysis of the design, introduction and implementation of seven
NHS TCs
An ongoing feedback process, ensuring that lessons learned from the seven case study sites
will help to improve services in the remaining TCs
As well as sharing findings among managers and clinicians in NHS TCs, the final results will
be shared widely with policymakers in the NHS, as well as disseminated in peer reviewed
(academic) journals
Innovative methods of practice fed directly into the NHS.
Potential risks and safeguards
The research team are aware of the sensitivities and ethics of researching in health care
settings and have extensive fieldwork experience in this area. They also have experience of
‘naturalistic’, unobtrusive research designed to minimise any disruption to staff or patients.
Verbal consent will be sought for all face to face interviews and for observation of any
meetings and day-to-day activities in the TCs. The team will reiterate all potential
interviewee’s rights to:
Withdraw from the project at any time
Stipulate for the removal of material from any transcripts that they believe is of a sensitive
nature
Withhold information.
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Because of unfamiliarity with the intricacies of the case study sites the research team ask that
a ‘link person’ (‘Site Captain’ or ‘Gatekeeper’) be assigned to advise on – and guide – entry
into the organisation and provide any relevant background information.
Confidentiality
Involvement in this research project is entirely voluntary and assurances will be given to
participants that all discussions and interviews are entirely confidential. All interviews and
fieldnotes will be coded and stored in a locked filing cabinet. Prior permission will be sought
– where appropriate – from the organisation for any tape-recording (interviews or meetings)
or photography undertaken as part of the study. It is intended that anonymous abstracts from
the interviews may be used in publications arising from this research but any materials will
not be used without the full permission of participants. The study team will ensure that it
adheres to the ‘Research Governance Framework.
Withdrawal and Rights of Research Subjects
Participants (organisation or individual) may withdraw from the study at any time without
prejudice or penalty.
Contact details for research team
Project lead: Professor Paul Bate, Chair of Health Services Management, CHIME, University
College London, London, N19 3UA; Email: [email protected], tel: +44 (0) 20 7380
9890.
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Appendix 2 Interview sampling grids for phase 1 and 2
Phase 1: inside TC
A B C D E F G H
Project ‘originators’ and site mgrs
Senior mgr resp for TC
Business/ops mgr (day-to-day)
Clinical lead
Nursing lead
Therapies lead
IS manager
Training and education
Facilities manager
Modernisation lead
Booking/scheduling
PALS/patient surveys and satisfaction
Theatres
Other clinicians
Nursing staff
Other
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Phase 1 and 2 trust level/host(s)
A B C D E F G H
Exec resp for TC/surgery
Chief executive
Human resources director
Director of finance
Director of nursing
Director of strategy/development
Medical director (surgery)
Capital projects/estates
Head modernisation team
Other
Booking/ scheduling
PALS/patient surveys and satisfaction
Theatres
Other clinicians
Nursing staff
Other
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Phase 1 and 2: meetings A B C D E F G H
Project co-ordination
Management board
Medical board
Modernisation board
Clinical governance board
Internal TC team meetings
Phase 2 external stakeholders
A B C D E F G H
PCT
Strategic health authorities
Patient groups/patient involvement (lead for TC)
Workforce confederation
Trade unions
Neighbouring trusts
Other
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Appendix 3 Literature review search methods
Issues related to the literature searching
The literature search was undertaken with the aid of Alison Price, Information
Officer at the Wessex Institute for Health R&D (WIHRD), University of
Southampton. At the outset, it was clear that there were at least four factors
which rendered a sharply focused ‘systematic review’ in the narrow sense
inappropriate and, indeed impossible.
• There was no single research question or clearly specified outcome
measure.
• The questions that were being asked were not, for the most part, ones
for which categorising and subsequent selection of retrieved literature in
terms of a methodological hierarchy was appropriate. Opinion
statements, policy documents etc were all potentially relevant. Thus
selection criteria have been largely ones of content and topic, rather than
methodological quality, although comments are made when relevant
about the possible status of any research evidence. Synthesis has been a
qualitative rather than quantitative process.
• The brief was mainly to identify literature on treatment centres as a
health care policy development, and an organisational innovation. Some
key refereed journals, and most of the non-research literature are not
included in Medline for this area. Alternative searching was undertaken,
but the extent of this was limited within the time constraints. Extensive
manual entry of retrieved literature into a project bibliographic database
was required.
• The terms ‘treatment centre’ and ‘diagnostic and treatment centre’ are
not well-established keywords in relevant databases. Free text searching
for these exact terms (or similar ones) produces thousands of hits
covering almost every kind of health care provider and more. (Some UK
‘treatment centres’ are penal reform institutions, and the abbreviation
‘DTC’ also stands for ‘direct to customer’ in advertising and sale of
pharmaceutical products). Searching under ‘ambulatory care centre/er’
generates much relevant literature, but also articles about US facilities
more akin to NHS ‘walk-in’ primary care centres, chronic illness care
services etc.
Searches undertaken
Electronic databases and journals
Essentially the strategy was to search databases including material on health
care organisation, or limiting Medline searches to this area, under the
following terms ‘treatment cent$’, ‘day surgery’, ‘surg$ cent$’, and ‘elective
surgery’, dating from 1984 or the start of the relevant database if later. Only
English language material was included and, for Medline, the search was
confined to UK, US, Canada and Sweden.
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In addition to the well-established databases serving the health services
research community, databases with fuller coverage of social science and
policy literature (SSCI, Econlit and EBSCO Business Source Premier) were
also searched. A number of key UK and US health care journals were
searched (online contents) for specific articles on treatment/surgical centres
and for generally relevant articles, for example on hospital restructuring as
this emerged as an important aspect of the general policy background.
Websites
The Department of Health’s website was searched on ‘treatment centres’ on
several occasions (because of the reconstruction of the site concurrent with
the literature search), with appropriate links being followed up, in particular
the Modernisation Agency’s website. The website for the Royal College of
Surgeons (England) was also scanned.
A number of web searches using the Google crawler engine were conducted
for example using ‘treatment centres’ and ‘ACAD Central Middlesex Hospital
Trust’ and ‘NHS Elect’ as exact terms. As is generally found in such searches,
many hits were found, many of which were duplicates of documents already
found (or of little relevance or questionable quality). However, this was the
main source for information from local NHS organisations.
‘Grey’ and background literature and personal contacts
Google and other online searches generated much ephemeral and
unpublished literature, including a number of documents produced by NHS
authorities and trusts relating to service development (although the extent to
which NHS institutions make such documents publicly available online is very
variable).
Other research teams
In the course of searching, and from background knowledge, two relevant
research teams were identified. A study, from an organisational theory
perspective, of the development of an innovatory Ambulatory Care and
Diagnostic Centre has been undertaken by current and ex-members of the
School of Management at Royal Holloway, University of London, led by
Professor Charles Harvey, now at the University of the West of England. Five
published papers, none of which were identified by the database searches,
have been obtained from this team. Please note that the archive relating to
the research work on the development of the relevant NHS hospital trust in
the 1990s is not currently in the public domain. Professor Charles Harvey
would be happy to answer specific queries ([email protected]).
Chris Howorth, Lecturer in Management at Royal Holloway, is working on a
PhD on this material ([email protected]).
The second team, led by Professor JA Bowers and Ms G Mould of the
Department of Management and Organisation, University of Stirling, has been
examining the organisational impact of introducing ambulatory care facilities
(and subsequently treatment centres), mainly through simulation exercises.
This team has supplied copies of one published and one draft article, a final
report for the chief scientist at the Scottish Health Department and details of
forthcoming papers. Website material has also been downloaded. For further
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information see
www.stir.ac.uk/departments/management&organisation/research or email
Background literature
In addition to specific searches, some analysis was undertaken of more
general background health services research and policy literature. For
example, some publications on wider aspects of NHS health care policy
developments, and health services research related to organisational change
and quality improvement initiatives etc are referred to in the report. This was
done to help contextualise the TC initiative, particularly because of the very
limited research literature found specifically on the development of TCs or on
what has been suggested as the closest US equivalent, surgical centers. That
there is little literature on TCs as such, in England to date, is not surprising,
given that they have been implemented recently. However ambulatory
surgical centers or similar have existed in the US for more than two decades.
Yet, scarcely any general articles about the history or impact of this specific
form of health care organisation were identified in mainstream health policy
journals. Reference to ambulatory surgical centers or equivalent is absent or,
at most, only made in passing, in a number of well regarded general articles
and books on recent developments in the US health care system (for example
Peterson, 1998; Scott et al, 2000; Shortell et al, 2000). While this absence of
discussion and analysis may reflect problems with the searching, it might also
indicate some of the following possibilities:
• that ambulatory surgical centers have become such a taken-for-granted
‘sector recipe’ in US health care that they now arouse little policy or
research controversy
• that, although growing, the ambulatory surgical sector is still too small to
be a major focus of interest
• that the surgical center as such is not a significant organisational form
within the dominant conceptual frameworks employed to analyse US
health care system developments. For example, while most (but not all)
surgical centers are ‘for-profit’ organisations, they are only one form of
this type of provider, the expansion of which is a major theme of US
health policy analysis. Similarly, they may be seen as only one of many
developments of the general process of hospital reconfiguration and
‘downsizing’ that forms the second main theme of current macro-level US
health policy analysis.
As a check for other general literature on ambulatory surgical centers a
request was posted on the MEDSOC email list (maintained at Brown
University). This is a very active list serving mainly the medical sociology
section of the American Sociological Association. Immediately prior to this
posting, there had been several threads concerning literature on health care
organisation topics. That only two replies were received may indicate that
ambulatory surgical centers are not in themselves a current topic for active,
critical social science research at present. Of the two replies, one suggested
the website for the Medicare Payment Advisory Committee (MedPAC), an
independent federal body established in 1997 ‘to advise the US Congress on
issues affecting the Medicare program’. MedPAC issues reports with
recommendations relating to Medicare payments, in March and June each
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year and holds public hearings. The March 2004 report contains much useful
factual information about Medicare funded ASC services and was downloaded
(MedPAC, 2004). Previous reports and hearings might also be informative but
have not been consulted in the time available. The second response
suggested parallels between NHS treatment centres and US free-standing
abortion clinics. This highlights the ambiguity of the term ‘elective’, but also
points to longstanding contractual relationships between the NHS and the
private and voluntary sector in this highly focused area of service provision
which may be a model for TCs.
Summary observations on the literature searching
Approximately 400 items were entered into an Endnote ‘library’ for the
project. Few of the retrieved items deemed directly relevant to TCs per se are
research articles in peer-reviewed journals. A decision was taken to
concentrate on the greyer, policy orientated literature in order to produce a
narrative about the development of TCs. Selection criterion was essentially
perceived relevance to the topic and inclusive of a wide range of sources. In
terms of established information databases, HMIC was probably the single
most useful source in that almost all retrievals were useful, and many were
not found through PubMed. It should be noted that much of the material
included emanates from government departments and agencies, and needs to
be interpreted accordingly. Gaps in the review include a lack of material on
the commissioning side (PCTs and GPs) or patients’ views as these do not
appear prominently in the literature as searched. Similarly, there is little on
nurses, although some attempt was made to search the nursing literature.
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MAIN SEARCH STRATEGIES AND RESULTS
Examples of the search strategies adopted at the beginning of the project are
given below. These are followed by tables giving the results of the initial
searches. Except where indicated these tables do not include all items added
to the bibliographic database during the review.
Table A1 Search 1
Date searched 04/05/04 Database: Ovid MEDLINE(R) <1966 to April Week 3 2004>
Search Strategy:
1 ambulatory care cent$.mp. (167)
2 Ambulatory Care/ (24548)
3 exp Ambulatory Surgical Procedures/ (6725)
4 day surgery.mp. (3414)
5 (diagnos$ adj3 treatment cent$).mp. [mp=title, original title, abstract, name of substance,
mesh subject heading] (131)
6 treatment cent$.mp. (3125)
7 (treatment adj2 (centre$ or center$)).mp. (3626)
8 independent treatment cent$.mp. (2)
9 elective care.mp. (11)
10 elective surgery.mp. (3581)
11 exp Surgical Procedures, Elective/ (2977)
12 dedicated unit$.mp. (47)
13 surgicent$.mp. (1123)
14 (ambulatory care adj3 diagnos$ cent$).mp. (1)
15 Outpatient Clinics, Hospital/ (10515)
16 1 or 5 or 8 or 12 or 14 (348)
17 2 or 3 or 4 or 9 or 10 or 11 or 13 or 15 (49338)
18 6 or 7 (4546)
19 hi.fs. (184640)
20 og.fs. (201339)
21 or/19-20 (383092)
22 17 and 19 (248)
23 18 and 19 (44)
24 [from 5 keep 3-4,13-14,51,74,77,82,102,104,107,111,114,121,127,130] (0)
25 (diagnos$ adj2 (treatment adj2 (centre$ or center$))).mp. (141)
26 *’Ambulatory Care Facilities’/ (3370)
27 16 (348)
28 limit 27 to (english language and yr=1984-2004) (261)
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(Table A1 continued)
29 [from 28 keep 4,8-10,19,21,24-25,36,52,54,56,70-72,78,82,85-86,89-90,92-93,101-
102,104-105,113-114,116-117,122,125,130,136,142,144,146,150,156,161,164-
165,171,181-183,185-186,188-189,192,198,200-204,206,210,212-215,218-221,225-
227,229-235,238,240,242-246,248-259] (0)
30 17 and 21 (5347)
31 7 and 20 (230)
32 31 not 29 (230)
33 [from 32 keep 1,11-13,19,62-63,73,92-93,100-101,117,120-121,135,138-
139,144,147,160,165,169,172,185-188,195,221] (0)
34 26 and 20 (1158)
35 34 and ut.fs. (100)
36 limit 35 to (english language and yr=1984-2004) (79)
37 [from 36 keep 2,11,16,20,29,42,46,49,68,76-77] (0)
38 surg$ cent$.mp. (1488)
39 13 or 38 (2363)
40 39 and 10 (10)
41 *’Surgicenters’/ (820)
42 from 40 keep 1,5,7-8,10 (5)
43 exp Surgicenters/og, ec, es, hi, td [Organization & Administration, Economics, Ethics, History,
Trends] (608)
44 from 43 keep 4,11,19,23-24,34,41,72,110-111 (10)
45 from 43 keep 110-111 (2)
46 exp Surgicenters/og (391)
47 Evaluation Studies/ (114779)
48 46 and 47 (4)
49 from 48 keep 1-4 (4)
50 47 and 38 (19)
51 from 50 keep 4,6-7,13,17 (5)
52 from 51 keep 1 (1)
53 1 or 5 or 6 or 7 or 8 or 13 or 14 or 38 or 41 or 43 (7051)
54 3 or 4 (9343)
55 10 or 11 (6003) Total intervention Set A
56 53 and 55 (25)
57 imit 56 to (english language and yr=1984-2004) (21)
58 exp Emergency Medical Services/ (48297)
59 exp Emergency Service, Hospital/ (22023)
60 58 or 59 (48297)
61 53 not 60 (6893)
62 from 57 keep 1-21 (21)
63 2 or 3 or 53 (37592) Total population Set B
64 63 and 55 (142)
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(Table A1 continued)
65 limit 64 to (english language and yr=1984-2004) (129) Final elective surgery issues
66 from 65 keep 2,4-7,9-10,13,18,21-22,24-25,27-28,30-42,44-50,52-56,58-60,63-70,72-
77,79-80,83-84,91-92,94-96,98,101-102,106-109,111,113,115,120-123,125-126,129 (83)
Download file
Table A2 Search 2
Database: EMBASE <1980 to 2004 Week 18> Search Strategy:
1 ambulatory care cent$.mp. (90)
2 Ambulatory Care/ (4429)
3 exp Ambulatory Surgical Procedures/ (3130)
4 day surgery.mp. (2843)
5 (diagnos$ adj3 treatment cent$).mp. [mp=title, abstract, subject headings, drug trade name,
original title, device manufacturer, drug manufacturer name] (104)
6 treatment cent$.mp. (2673)
7 (treatment adj2 (centre$ or center$)).mp. (3154)
8 independent treatment cent$.mp. (3)
9 elective care.mp. (7)
10 elective surgery.mp. (7400)
11 exp Surgical Procedures, Elective/ (5441)
12 dedicated unit$.mp. (25)
13 surgicent$.mp. (42)
14 (ambulatory care adj3 diagnos$ cent$).mp. (0)
15 Outpatient Clinics, Hospital/ (4520)
16 1 or 5 or 8 or 12 or 14 (222)
17 2 or 3 or 4 or 9 or 10 or 11 or 13 or 15 (21410)
18 6 or 7 (3970)
19 hi.fs. (0)
20 og.fs. (0)
21 or/19-20 (0)
22 17 and 19 (0)
23 18 and 19 (0)
24 [from 5 keep 3-4,13-14,51,74,77,82,102,104,107,111,114,121,127,130] (0)
25 (diagnos$ adj2 (treatment adj2 (centre$ or center$))).mp. (114)
26 *’Ambulatory Care Facilities’/ (812)
27 16 (222)
28 limit 27 to (english language and yr=1984-2004) (177)
29 [from 28 keep 4,8-10,19,21,24-25,36,52,54,56,70-72,78,82,85-86,89-90,92-93,101-
102,104-105,113-114,116-117,122,125,130,136,142,144,146,150,156,161,164-
165,171,181-183,185-186,188-189,192,198,200-204,206,210,212-215,218-221,225-
227,229-235,238,240,242-246,248-259] (0)
30 17 and 21 (0)
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(Table A2 continued)
31 7 and 20 (0)
32 31 not 29 (0)
33 [from 32 keep 1,11-13,19,62-63,73,92-93,100-101,117,120-121,135,138-
139,144,147,160,165,169,172,185-188,195,221] (0)
34 26 and 20 (0)
35 34 and ut.fs. (0)
36 limit 35 to (english language and yr=1984-2004) (0)
37 [from 36 keep 2,11,16,20,29,42,46,49,68,76-77] (0)
38 surg$ cent$.mp. (1076)
39 13 or 38 (1114)
40 39 and 10 (20)
41 *’Surgicenters’/ (812)
42 from 40 keep 1,5,7-8,10 (5)
43 [exp Surgicenters/og, ec, es, hi, td [Organization & Administration, Economics, Ethics, History,
Trends]] (0)
44 [from 43 keep 4,11,19,23-24,34,41,72,110-111] (0)
45 [from 43 keep 110-111] (0)
46 [exp Surgicenters/og] (0)
47 Evaluation Studies/ (23960)
48 46 and 47 (0)
49 [from 48 keep 1-4] (0)
50 47 and 38 (14)
51 [from 50 keep 4,6-7,13,17] (0)
52 [from 51 keep 1] (0)
53 1 or 5 or 6 or 7 or 8 or 13 or 14 or 38 or 41 or 43 (5964)
54 3 or 4 (5486)
55 10 or 11 (7400)
56 53 and 55 (23)
57 limit 56 to (english language and yr=1984-2004) (16)
58 exp Emergency Medical Services/ (7261)
59 exp Emergency Service, Hospital/ (7261)
60 58 or 59 (7261)
61 53 not 60 (5937)
62 [from 57 keep 1-21] (0)
63 2 or 3 or 53 (13197)
64 63 and 55 (133)
65 limit 64 to (english language and yr=1984-2004) (116)
66 [from 65 keep 2,4-7,9-10,13,18,21-22,24-25,27-28,30-42,44-50,52-56,58-60,63-70,72-
77,79-80,83-84,91-92,94-96,98,101-102,106-109,111,113,115,120-123,125-126,129] (0)
67 from 65 keep 7-8,10-11,13-16,18-31,34,37-39,41,44-48,50-59,61-63,65,67-70,72-74,77,79-
86,88-93,95-96,98,100,103-105,108-110,112-113,115-116 (82) Download file
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Table A3 Search 3
Database: HMIC Health Management Information Consortium <May 2004 Search Strategy:
1 ambulatory care cent$.mp. (17)
2 Ambulatory Care/ (130)
3 day surgery.mp. (404)
4 (diagnos$ adj3 treatment cent$).mp. [mp=title, other title, abstract, heading words] (34)
5 treatment cent$.mp. (280)
6 (treatment adj2 (centre$ or center$)).mp. (313)
7 independent treatment cent$.mp. (1)
8 elective care.mp. (20)
9 elective surgery.mp. (216)
10 dedicated unit$.mp. (8)
11 surgicent$.mp. (2)
12 (ambulatory care adj3 diagnos$ cent$).mp. (5)
13 (diagnos$ adj2 (treatment adj2 (centre$ or center$))).mp. (32)
14 surg$ cent$.mp. (32)
15 1 or 2 or 4 or 5 or 6 or 7 or 11 or 12 or 13 or 14 (484)
16 3 or 8 or 9 (622)
17 15 and 16 (28)
18 limit 17 to yr=1984-2004 (28)
19 from 18 keep 1-28 (28) Download file
Table A4 Search 4
BNI Database: British Nursing Index (BNI) <1985 to March 2004> Search Strategy:
1 ambulatory care cent$.mp. (5)
2 Ambulatory Care/ (0)
3 day surgery.mp. (560)
4 (diagnos$ adj3 treatment cent$).mp. [mp=heading words, title] (3)
5 treatment cent$.mp. (23)
6 (treatment adj2 (centre$ or center$)).mp. (34)
7 independent treatment cent$.mp. (0)
8 elective care.mp. (0)
9 elective surgery.mp. (23)
10 dedicated unit$.mp. (0)
11 surgicent$.mp. (2)
12 (ambulatory care adj3 diagnos$ cent$).mp. (0)
13 (diagnos$ adj2 (treatment adj2 (centre$ or center$))).mp. (3)
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(Table A4 continued)
14 or/1-13 (622)
15 14 not (3 or 9) (39)
16 limit 15 to yr=1984-2005 (39)
17 16 not (5 or 6) (6)
18 [from 17 keep 7] (0)
19 1 or 4 or 5 or 6 or 11 or 12 or 13 (42)
20 19 not (5 or 6) (7)
21 [from 20 keep 2-11,14-16,18,21-22] (0)
22 treatment centre$.mp. (22)
23 diagnostic & treatment centre$.mp. (1)
24 ACAD.mp. (0)
25 exp AMBULATORY CARE/ (0)
26 or/22-25 (22)
27 (diagnostic and treatment centre$).mp. [mp=heading words, title] (1)
28 (or/26) or 27 (22)
29 investment.mp. and reform for NHS hospitals.ti. [mp=heading words, title] (0)
30 ‘REFORM’/ (0)
31 ‘NHS PLAN’/ (0)
32 26 and (30 or 31) (0)
33 [from 32 keep 1,3-6] (0)
34 28 and 31 (0)
35 34 not 33 (0)
36 28 and 30 (0)
37 surgicent$.tw. (2)
38 [from 21 keep 1-10] (0)
39 [from 21 keep 1-10] (0)
40 4 or 13 or 23 or 27 (3)
41 40 not (33 or 21) (3)
42 from 41 keep 1 (1)
43 [from 41 keep 1,3-17,19-30] (0)
44 from 4 keep 1-3 (3)
45 4 or 13 or 23 or 27 or 37 (5)
46 45 not 44 (2)
from 46 keep 1 (1)
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Table A5 Search 5
CINAHL Database: CINAHL <1982 to April Week 1 2004> Search Strategy:-
1 ambulatory care cent$.mp. (38)
2 Ambulatory Care/ (2179)
3 day surgery.mp. (646)
4 (diagnos$ adj3 treatment cent$).mp. [mp=title, cinahl subject headings, abstract,
instrumentation] (21)
5 treatment cent$.mp. (346)
6 (treatment adj2 (centre$ or center$)).mp. (452)
7 independent treatment cent$.mp. (0)
8 elective care.mp. (2)
9 elective surgery.mp. (176)
10 dedicated unit$.mp. (14)
11 surgicent$.mp. (794)
12 (ambulatory care adj3 diagnos$ cent$).mp. (1)
13 (diagnos$ adj2 (treatment adj2 (centre$ or center$))).mp. (18)
14 or/1-13 (4186)
15 14 not (3 or 9) (3373)
16 limit 15 to yr=1984-2005 (3281)
17 16 not (5 or 6) (2796)
18 from 17 keep 7 (1)
19 1 or 4 or 5 or 6 or 11 or 12 or 13 (1320)
20 19 not (5 or 6) (829)
21 from 20 keep 2-11,14-16,18,21-22 (16)
22 treatment centre$.mp. (94)
23 diagnostic & treatment centre$.mp. (4)
24 ACAD.mp. (92)
25 exp AMBULATORY CARE/ (2179)
26 or/22-25 (2363)
27 (diagnostic and treatment centre$).mp. [mp=title, cinahl subject headings, abstract,
instrumentation] (6)
28 (or/26) or 27 (2363)
29 investment.mp. and reform for NHS hospitals.ti. [mp=title, cinahl subject headings, abstract,
instrumentation] (0)
30 ‘REFORM’/ (0)
31 ‘NHS PLAN’/ (0)
32 26 and (30 or 31) (0)
33 [from 32 keep 1,3-6] (0)
34 28 and 31 (0)
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(Table A5 continued)
35 34 not 33 (0)
36 28 and 30 (0)
37 surgicent$.tw. (14)
38 from 21 keep 1-10 (10)
39 from 21 keep 1-10 (10)
40 4 or 13 or 23 or 27 (25)
41 40 not (33 or 21) (25)
42 from 41 keep 1 (1)
43 [from 41 keep 1,3-17,19-30] (0)
44 from 4 keep 1-3 (3)
45 4 or 13 or 23 or 27 or 37 (39)
46 45 not 44 (36)
47 from 46 keep 1 (1)
48 1 or 4 or 12 or 13 or 23 or 27 or 37 (78)
49 limit 48 to (english and yr=1984-2004) (73)
50 from 49 keep 4,6,9-10,19-22,35,40,48-49,57,66,70,72 (16)
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Table A6 Record sheet of initial WIHRD searches
Databases
Years searched
Date of search and strategy saved name
Number of hits (download file)
Number of items retained in database after scrutiny and elimination duplicates
Medline
1966-March
week 3 2004
31/03/04
182 137
Medline 1966 to
April Week 3
2004>
04/05/04
med-elective2
83 32
Embase
1984-2004
Week 14
05/04/04 34 12
EMBASE <1980
to 2004 Week
18>
05/04/04
emb-elective
82 25
PubMed (limit
to last 90
Days)
23/04/04 1 1
HMIC 06/04/04 28 22
CINAHL 06/04/04 16 12
SCI/SSCI 21/04/04 7 7
BNI 06/04/04 5 5
ASSIA 06/04/04 7 5
NHS-CRD 21/04/04 0
EconLit 84-04
(( surg* cent*
)or( treatment
cent* )or(
surgicent* ))
and (PY:ECON
=
1984-2004)
30/04/04
10 10
Health Affairs
Journal
Surg* cent* 19 19
Total references 474 287
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Table A7 Initial searches undertaken by MAE: April-June 2004
Database or source
Years searched
Search strategy/date
Number of hits: initial searches
New references added to database
King’s Fund information
service: 1984-March
2004
surg* cent* OR elective
surg* OR day surg* OR
ambulatory care
73 33
Business Source Premier
1984-May 2004
(surg* cent*) 77 14
Jnl of Health Services
Research & Policy:
1999-2004
Scanned for relevant
papers (including
general background)
6 4
Milbank Quarterly:
1994-2004
Scanned for relevant
papers (including
general background)
8 8
Jnl of Health Policy,
Politics & Law:1994-
2004
Scanned for relevant
papers (including
general background)
3 3
British Medical Journal:
1995-2004
(in addition to Medline
search)
Health care organisation
collection scanned for
background
15 10
Managed Care surg* cent* 24 6
Royal College of
Surgeons website
Day Surgery OR
Treatment Centres
6 3
Department of Health
(incl. modernisation
agency) website
Treatment Centres
Ongoing throughout
n/a 19
Health Service Journal Ongoing hand search
April 2004-Sept 2005
n/a 24
Google Searches
10/03/04 & 11/05/04
ACAD Central Middlesex
Hospital Trust
First 100 of 1200 hits
scanned
11
Development and implementation of NHS treatment centres
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Appendix 4 Interview topic guides
Organisationally focused interviews: semi-structured, tape-recorded
Who: Key stakeholders within /outside the organisation
Aim: develop understanding(s) of the interpretations associated with TCs and
how these change and develop over time; understand and clarify the
meanings people attach to:
• TCs – early and altering views, speculations and understandings (for
example physical/virtual). How will things change over next year (and
why?).
• Patients – how ways of working with patients differs from ‘traditional’;
how does the patient/carer ‘experience’ TC; assessment/evaluation of
practice (formal and informal QA); degree of commitment to new
working (cut across professional groups involved in delivering service).
• Wider organisation(s) – relationships and how these are maintained (or
not); formal and informal structures.
• Each other – difficult/easy to adopt new philosophy/approaches; new
behaviours and attitudes, quality of relationships, morale, enthusiasm
and commitment.
• Their job/experience; role (extended/expanded), tasks, work patterns,
compared to other work experiences, aspirations, motivation and
rewards.
• The wider learning partnership – TC networks, MA, other support groups/
networks.
Key areas for interviews (note: questions can be ‘grounded’ in critical
incidents and real-life experiences and events of both patients and staff).
• identity, values, ethos, ideology and commitments (personal/cultural)
• relationship with key constituents
• mission and strategy (type/how formed; operationalised as
policy/monitored)
• change model/underlying theory of change
• establishing existing/new/altered changes in practices (for example
service redesign activities)
• changes in cultural norms/rules
• leadership and decision making – who and how it is exercised
• teams and team working; group dynamics – within and between teams
(in/out of TC)
• motivation, commitment and reward
• organisational structure and structuring
• performance measurement and management
• quality and governance issues
• skills, training and development
• politics and political processes
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• HR aspects (including stress)
• IS/IT aspects
• information and communication.
Prompts
• Role and career history – talk through a role map and key relationships.
• When did you first hear of TCs / this TC; how did you come to be
involved?
• What were your initial perceptions/expectations/anxieties) – and now?
• What have been the main shaping factors in this TC’s development
(phases/events)
• Can you recall the main challenges early on; what was your response to
these?
• So how are things going now? (highlight high and low spots – and any
related actions)
• What are the priorities/your predictions for the immediate future?
• External:
- is there central policy support for rationale / underlying principles?
- divergent perspectives and aspirations between actors and
stakeholders
- short-term operational targets vs longer-term ‘vision’ espoused by TCs
- understanding/co-operation between local trusts and PCTs
- impact on other trusts waiting lists and activity targets
- existing commissioning arrangements hinder or support the operation
of TCs
- local politics
• Host organisation:
- what was it like before the TC?
- what are the ‘politics’ associated with the implementation
- what are your views on the development and organisation of the TC?
- does the organisational structure facilitate or impede TC development?
- infra-structural support (for example IT, equipment, training)?
- is the TC perceived as/treated as, a ‘closed’ system by the wider
organisation?
• The TC itself:
- what is the underlying philosophy of the TC?
- who was involved in developing this philosophy?
- how easy / difficult has it been to implement this philosophy?
- staff involvement in development and operationalisation of this
philosophy?
- how has the developmental process and any other change processes
been led?
- does the physical environment match the aims and rationale of the TC?
- are the staff excited (and motivated) by the novel approach of the TC?
- skill mix/workforce planning adequately and imaginatively addressed?
- communication, information management/scheduling systems –
sufficient?
- how were the ICPs agreed, implemented and monitored?
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- how is the interface with PC, intermediate care and social services
managed?
- what challenges currently face the TC and how are they being
addressed?
- interact/influence other TCs?
- what lessons has this TC learnt from others?
- how have lessons learnt in this TC been communicated to others?
- how does the TC interact with the Modernisation Agency- influence?
Also probe:
• IT
• knowledge management
• HR in relation to workforce planning and training and development
• clinical governance
• the processes through which ‘evidence’ and ‘experts’ contribute to
redesign
• the politics of change
• cultural change
• the overall management of the change management process itself.
Documentary data collection
Where possible obtain copies of relevant documents for example:
• business plans
• design brief/ drawings
• minutes from internal TC team meeting, boards
• protocols and guidelines; care pathways
• key sources of information such as guidance for clinicians,
• information sheets and booklets provided to patients and their carers
• publicity materials.
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Appendix 5 Results of CHIME survey of treatment centres
Type of TC TC
branding
Example of
modernisation
Difference in
productivity
Expectations
met
Impact on
waiting
times
Incentivisation Operational
challenges
now
Lessons for
new TCs
A PCT,
consultant-led,
multi-specialty,
add on to
existing
community
hospital, day
case only
Yes – as a
diagnostic
and
treatment
centre
Nurse-led
endoscopy
service, looking
at more nurse-
led initiatives
Yes due to extra
theatre, surgical
staff and services
rather than
modernisation.
Too early to say
what impact of
modernisation will
be
Definitely Certainly
lighter;
always been
quite short
anyway,
some
improvement
though
No. Existing
contract,
sessional
payment
Looking at
how we
manage
capacity in
the future
More realistic
timescales
Clinical
involvement
from day one
Reviewing skill
mix
Budget for
upgrading
equipment
B Virtual – 3
distinct areas,
single specialty
Yes Supported
discharge team
(multi-
disciplinary)
We have tried to
modernise what
we do, with that
we have improved
productivity and
the capacity is
greater than it
was. With
modernisation
does come greater
productivity
Not overall.
Still dealing
with long
waiters who
are complex
cases. In a
better
position than
this time last
year but still
struggling to
meet the 12
month target
No Patient and
staff
expectations
(e.g. 23 hour
stay);
cultural
challenges
that come
with new
extended
roles
Abbreviations: LOS = length of stay; GPSI = general practitioners with special interests; LPC = London Patient Choice
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Type of TC TC
branding
Example of
modernisation
Difference in
productivity
Expectations
met
Impact on
waiting
times
Incentivisation Operational
challenges
now
Lessons for
new TCs
C Cataracts and
orthopaedics
Yes – as a
diagnosis
and
treatment
centre
Pre-
assessment;
Scheduling
Group (learnt
from US); new
staff (especially
nursing roles);
hip and knee
club and patient
interaction
Increase in
productivity (LOS
down from 9+
days to 5-7 days
for hips and
knees) because of
additional
surgeons/
theatres; pre-
assessment
possible because it
is elective surgery
only
Cataracts:
down from
12 months to
3 weeks but
now demand
not there so
reducing
sessions
No (but some
reimbursement
for extra travel)
Excess
capacity: lack
of demand
and IS TC on
the way.
Funding
implications.
Uncertainty
re impact of
Patient Choice
from next
year, trusts
only referring
long-waiters
Instrumentation
Financial flows
PCT
engagement
Scheduling
group
D Virtual – 5
distinct areas
Yes – as a
TC (but
difficult as
virtual)
Urology: one
stop
haematuria
clinic, nurse-led
cystoscopy
Orthopaedics:
joint
assessment
team, patient
education
Urology: yes.
Orthopaedics: in
its infancy
P: yes, in terms
of plans
C: no – looking
for better
structure to be
in place. Hasn’t
gone far enough
Haven’t had to
yet; not saying
we won’t but not
yet
Buy-in from
clinicians;
Foundation
status (more
change)
Get clinical staff
on board; have
vision and
understand it
extremely well;
sell it to
clinicians like
you’ve never
sold before
Strict project
management
Do eligibility
criteria and
patient journey
as early as you
can
Development and implementation of NHS treatment centres
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Type of TC TC
branding
Example of
modernisation
Difference in
productivity
Expectations
met
Impact on
waiting
times
Incentivisation Operational
challenges
now
Lessons for
new TCs
E LPC Yes – as a
diagnosis
and
treatment
centre at
moment but
will be as a
TC
No innovation
around staffing,
recruitment and
process,
theatres the
same. P: 'run
along totally
traditional
lines', 'staffed
in a traditional
way'
LOS the same Not met
business plan;
not met income
targets
Helped to
achieve it;
avoided
breaches and
that’s the
whole
function
really
Going to pay
medical staff for
the work done
as opposed to as
an extra bonus if
they do extra
work. They get
paid per item as
opposed to per
day or per half
day
C:
Infrastructure
not in place;
maintaining
relationships
to keep work
coming in
P: filling
capacity,
justifying
activity and
income;
coming up
with firm
strategy and
timescale
C: Know how
much funding
you have
P: think about
admission
processes very
carefully;
matching staff
skillmix to
patient demand
F Virtual,
cataract
(purpose built
ophthalmic
suite) and
orthopaedics
(new theatre,
25-30 beds
combined from
existing ward
and day
surgery unit)
Orthopaedics:
cut at least one
visit, electronic
booking
system, theatre
staff trained to
advanced
health care
assistants
Promised
referrals from
neighbouring
PCTs never
materialised;
possibility that
ophthalmology
TC will have to
close when lists
get down to 3
months
9-month wait
for
orthopaedics
at moment -
longest wait
list; aiming
for 6 months
by August
2004
Ophthalmology:
consultants will
get paid per
patient with a
bonus if targets
achieved
P: we've been
carrying all the
risk 'don't lay a
brick until you
have the work
signed in blood
by the PCTs'
Development and implementation of NHS treatment centres
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Type of TC TC
branding
Example of
modernisation
Difference in
productivity
Expectations
met
Impact on
waiting
times
Incentivisation Operational
challenges
now
Lessons for
new TCs
G C: just an
extra
orthopaedic
operating
theatre, 'it's a
waiting list
initiative not a
treatment
centre', beds
not protected
P:
ophthalmology
better fits US
surgi-center
notion
C: no,
'anyone who
opens their
mouth in
my
presence
and calls it
a TC gets
me jumping
down their
throat very
fast'
C: pre-
assessment
clinic but 'no,
because nobody
has given us
any money'
P: delayed
transfer of care,
moving
inpatient work
to day case, 23
hour facility;
cataract
pathway
C: we're more
productive than
we were a year
ago but then we
were more
productive a year
ago than we were
the year before
that. LOS will
continue to
decrease but less
potential for
theatre usage
P: LOS has come
down by 0.6 since
start of year but
massive increase
in referrals
P: no, the US
model has been
watered down
to a capital
project
programme
C: not yet,
waiting list
still a year
but operating
theatre only
been open
for about 8
weeks.
Hasn't
registered at
moment
P: cataract
waiting times
just under 6
months now,
hoping to get
it down to
just above 3
by March
2004
C: considered
certainly but
didn't have
money. Would
achieve a lot if
we could
Income
streams; in
short term,
the
expectation
of the health
economy on
what we can
put through;
in long term,
selling some
of the
capacity
C: don't start
without any
revenue;
P: get business
plan done
properly first,
have activity
signed up
before you
even start,
involve
clinicians as
early as
possible, look
to fast
turnover, high
volume, build
separately from
main hospital
Development and implementation of NHS treatment centres
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Type of TC TC
branding
Example of
modernisation
Difference in
productivity
Expectations
met
Impact on
waiting
times
Incentivisation Operational
challenges
now
Lessons for
new TCs
H C: 'the
diagnosis and
treatment
centre that
was planned
for this trust
has not gone
ahead' but
funding for
new eye unit is
in line with
philosophy of
diagnosis and
treatment
centres.
Outpatient
ophthal.
P: no,
'although
it's called a
TC it's
actually an
extended
day unit'
C: pre-
assessment
process,
efficient use of
operating
theatres, book
directly onto
lists
C: moved from
four to six cataract
operatons per list,
30% improvement
in outpatients
P: in some areas
yes, it's quite
slow. Too early -
'if we had the staff
earlier and more
time to focus on
some of the
process mapping
re-engineering, I
think we'd have
got more of that'
C: no as don't
have single,
integrated
building and a
learning culture,
but productivity
gains
'unexpectedly
effective'
C: massively
reduced,
gone down
from about
nearly 2000
patients
waiting to
about 400 in
two years
P: improved
access for
elective
surgery,
access has
significantly
improved
C: no, haven’t
addressed but
some of
operating lists
do seem to be
worth an
incentive
scheme as
productivity is
more important
than the actual
unit staff cost
P: have done
(paid per case)
to a small extent
with additional
contracted
activity
P: converting
inpatients
into day
patients
C: reach
consensus on
productivity
expectations on
individual
operating lists
at an early
stage; don't
forget
infrastructure
to back up
broader aims of
a TC
P: get given
more time,
appoint a full
time project
office and have
different sub-
groups, have a
clinical lead
clearly
identified, do
the demand
capacity
planning early
enough, train
staff earlier
Development and implementation of NHS treatment centres
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Type of TC TC
branding
Example of
modernisation
Difference in
productivity
Expectations
met
Impact on
waiting
times
Incentivisation Operational
challenges
now
Lessons for
new TCs
I A process not a
building'; six
projects lasting
18 months
(ophthal., day
surgery,
general
surgery,
orthopaedics)
No: closes
in
December
2003; no
longer
funded after
that
Gynae: one-
stop clinic
Not in the first
year - we were
600 cases under
our plan although
overall
productivity went
up significantly.
This year
improved
significantly.
Orthopaedics: LOS
down to 4 days for
hips and knees
Very successful
where dedicated
discrete
facilities (e.g.
ophthalmology)
; various levels
of success after
that
Will achieve
a month wait
by December
2003. Been a
major
achievement:
echo
ultrasound
waits went
from six
months to 6
weeks and
MRI from 3
months to 4
weeks.
Gynae: 80
surgical
patients
better than
expected (6
month waits)
as they so
efficient in
patient flow,
same for OP
waits
No. Considered
but dismissed.
Didn't feel could
give one group
of staff an
incentive against
another group of
staff. Just wasn't
feasible
Closing -
financial
reasons, no
money left
Project
managers need
clinical
credibility and
organisational
knowledge;
robust project
management
and good audit
trail from
outcomes and
QI and financial
flows;
timescales were
ludicrous
Development and implementation of NHS treatment centres
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Type of TC TC
branding
Example of
modernisation
Difference in
productivity
Expectations
met
Impact on
waiting
times
Incentivisation Operational
challenges
now
Lessons for
new TCs
J Added 1
orthopaedic
theatre to 3
pre-existing;
'we were
probably
always a TC,
even before it
actually
happened'
No. Staff,
PCTs and
patients
wouldn't see
anything
different
from what
we used to
do. Starting
to go
through that
process
Developed a
health care
assistant role -
releases trained
staff to
concentrate on
other duties
TC programme has
shown we are a
little of pace in
productivity terms.
Best we've been
able to do in past
is 3 in an all-day
list but looking to
do 4 in future -
down to service
redesign, looking
at patient journey
and joining up
pieces of the
jigsaw
Surgeons paid
waiting list
initiatives,
overtime on a
cost per case
basis - helped
gee-up the
system
Can do better
re productivity
- want to
work with
clinicians to
improve
throughput/
performance
Challenge of
Patient Choice
- heard horror
stories across
the NHS that
new TCs have
been built but
no agreement
in place to
move patients
across to it
Takes longer
to achieve
than you
imagine - have
to change the
culture of the
workforce
Bricks and
mortar are
reasonably
straightforward
but persuading
people to work
differently and
to change long
established
clinical
practices is
harder
K Temporary
operating
theatre
(orthopaedics)
; (phase 2 in
2004 - new
diagnosis and
treatment
centre
building)
Yes -
keeping the
name
diagnosis
and
treatment
centre (as
doing
diagnosis as
well as
treatment)
Little or no
modernisation
or changes in
practice. Phase
2 will look at
modernisation
Greater
productivity (10-
25%) due to extra
theatre not
modernisation
Increasing
capacity by
employing extra
consultant and
having additional
operating space
Mean waiting
time is 3-4
months, was
8-9 months
No. Varied
thoughts around
that - evening
operations and
using spare
capacity for
surgeons
wanting to do
private work on
site. Haven't
discussed fee-
Looking at
opportunities
for changing
care
pathway,
getting
optometrists
involved,
doing pre-
assessment a
little earlier
Co-locate
outpatients
near theatres
and other
components of
the service
Development and implementation of NHS treatment centres
Queen's Printer and Controller of HMSO 2007 Page 266
for-service at all
Type of TC TC
branding
Example of
modernisation
Difference in
productivity
Expectations
met
Impact on
waiting
times
Incentivisation Operational
challenges
now
Lessons for
new TCs
L PCT diagnosis
and treatment
centre
(virtual). GPSI
led diagnostic
service
Yes - will
keep
diagnosis
and
treatment
centre
identity
GPSI
developments,
nurse lead
roles, multi-
professional
approach to
service delivery
Increased
productivity
around putting
extra capacity into
the system
Little slow on
uptake but
grew as people
became aware
of services.
Created extra
capacity around
endoscopy and
vascular
assessment,
made services
more accessible
(pre-operative
assessment)
and Patient
Choice (3
locations)
No Got to make
sure TCs
work at full
capacity
Engaging acute
consultants -
how to sell you
services,
developing
clinical
champions.
PCTs have got
to sign up to
GPSIs
M PCT diagnosis
and treatment
centre. GPSI
service (main
TC due open
2005): just
one session a
week. P: 'we
refer to it as a
GPSI, an
enhanced
practice'
No -
marketed as
a
dermatolog
y GP clinic
Was seeing 12
patients per
session but has
fallen to 7-8 after
nursing staff
vacancy
P: extremely
beneficial to
patients. Putting
a second GP in
to expand
service.
Demand and
patient
expectation
seems to be
increasing all
round
Conflicting
information
between P + C
P: waiting list
reduced to
three weeks;
C: list reduced
initially but
referral rates
increased (from
initial three
weeks) waiting
times to 3-6
mths
No. Paid per
session
Been so
popular is a
victim of its
own success
- getting so
many
referrals are
struggling to
cope
Logistically
getting all
equipment in
place asap
Development and implementation of NHS treatment centres
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Impact fairly
small to start
with
Type of TC TC
branding
Example of
modernisation
Difference in
productivity
Expectations
met
Impact on
waiting
times
Incentivisation Operational
challenges
now
Lessons for
new TCs
N Development
of pre-existing
service;
purpose built,
LPC
Signposted
as day unit
Benefits of
economies of
scale and
limited to
cataract
surgery. Staff
are willing to
experiment
Yes has met
productivity
targets set by
Patient Choice
Has met
expectations as
a testing ground
for streamlined
developments
from the ground
up
Have reduced
waiting lists
from 6 to 3
months
No (other than
very localised
temporary
arrangements
for junior staff)
C: problems
with
fluctuating
numbers
each week,
uneven
patient flows.
Planning and
maximising
use of weekly
system
(Patient
Choice)
Look carefully
at future
demand and
changes in
demand or else
will have excess
capacity and
large number of
days with too
few patients
O Virtual elective
centre, LPC
No - not
branded as
a diagnosis
and
treatment
centre, want
it to be seen
as part of
mainstream
hospital
Yes - quantifiable
in the reduction in
the length of stay
for knee
replacement from
12 to 5 days
Yes and no. In
some parts
good, in some
parts we've got
a lot more work
to do
Fee for service
in
ophthalmology
and general
surgery. Use the
BUPA rates and
pay 80% of that
Marketing to
take NHS
patients or
will have to
close as
premium on
the price to
pay for
empty
capacity;
theatre
efficiency and
recruiting
anaesthetists
Make sure your
scheduling is
right; start
early on job
descriptions
and
recruitment;
good
communication
all the time
(pre-
assessment,
theatres and
ward); have a
champion
Development and implementation of NHS treatment centres
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Development and implementation of NHS treatment centres
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Appendix 6 An example of a patient pathway
Referral with USS
Outpatients
Exclusions for day surgery
Male Age > 60 ASA Grade 3 Unfavourable USS Need for IO cholangiogram Previous abdominal laparotomy Patient to be given information leaflet from intranet
USS
Report on: - biliary tract - contracted gall bladder - gall stones - thick wall
Pre-operative assessment - to use staff assessment
guide
TCI date confirmed
(morning list)
Day of surgery - 7am admission - to admission lounge - walk to theatre - 1
st patient to be at theatre for
8.30am
Anaesthetic - Paracetamol 1g iv at induction - Paracoxib 40mg iv at induction - anti-emetics as per protocol
Recovery - 30 minutes - use of Pain and PONV scoring - avoid opioids if possible
Post operative care (ward) (8 hours)
- diet and fluids tolerated - analgesia - regular anti-emetic - ambulate patient
Discharge (Review by medical team post-op or nurse to contact medical team by phone) - pain control adequate - tolerating diet/fluid with no evidence of nausea or vomiting - no wound leakage - competent adult to help home and stay with overnight - access to landline
4 weeks post-op Telephone follow up by senior nurse
Discharged to GP
Daycase laparoscopic cholecystectomy
Patient visits 2 Surgeon Mr M… Anaesthetist Dr D… Pathway development lead S…
To be listed
Back to surgeon to agree date in
diary
Ward attend if necessary
One Stop
2 weeks prior to surgery
- health screening questionnaire (Pre-op team)
Note: USS = ultrasound scan; TCI = target-controlled infusions; PNV = post-operative nausea and vomiting
General practice
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Appendix 7 Department of Health’s health reform framework
Source: Department of Health (2005f)
Development and implementation of NHS treatment centres
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Appendix 8 Applying the Greenhalgh et al model to NHS treatment centres in general
Key questions Typical features of NHS treatment centres
1 The innovation
Key attributes of the innovation as perceived by
intended user:
(a) relative advantage Potentially high (separation of elective and emergency work and all ‘knock on’ benefits from that); perceived
improvements in quality and quantity of care, and in kudos for local NHS, Department of Health, and
Government; chance to alter patient pathways and professional roles
(b) compatibility Compatible with values of most clinicians although some staff view as part of the ‘break up’ of the NHS; patient
satisfaction likely to be very high as meets needs of fast and reliable access
(c) complexity The concept of TCs is simple to understand but implementation is complex (i.e. multi-disciplinary, multi-
professional, often reliant on complex realignments of staff and facilities)
(d) trialability Relatively easily trialable but not easy to evaluate longer-term and system-wide impacts formally
(e) observability Reasonably observable (e.g. high profile of pilot sites such as Central Middlesex Hospital’s Ambulatory Care and
Diagnostic Centre)
(f) reinvention (the extent to which the innovation
is changed or modified by the user in the process
of adoption and implementation)
High potential for reinvention
Key operational attributes:
(a) relevance to task High task relevance (i.e. fast and efficient treatment for patients)
(b) usefulness for task Potentially high usefulness in terms of improving patient care
(c) feasibility Variable feasibility, but by virtue of its adaptability and capacity for reinvention it can be made to be feasible just
about anywhere if other conditions permit
(d) implementation complexity High implementation complexity (in terms of numbers of ‘response barriers’ that must be overcome in order to be
Development and implementation of NHS treatment centres
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Key questions Typical features of NHS treatment centres
implemented successfully)
(e) divisibility into components Possibly divisible, but usually adopted as a whole rather than incrementally
(f) nature of knowledge needed On the one hand mostly highly codifiable and transferable (e.g. patient pathways). On the other hand ,tacit and
sticky as regards local implementation
2 Adoption and assimilation
Who are the potential adopters and what are their
characteristics and needs?
Broad range of senior managers and senior clinicians with differing needs and expectations
What is the meaning of the innovation to intended
adopters?
For most, a way of improving and systematising patient care; for some, income generation for their organisation;
for others, building organisational/individual reputation; for some, a chance to promote new professional roles
What is the nature of the adoption decision? Authoritative
What are the concerns of adopters at:
(a) pre-adoption stage
(b) early-use stage
(c) experienced user stage, and to what extent
are they met?
Predominantly financial at all stages (with concerns regarding governance arrangements too):
(a) securing capital funding for project, persuading key staff to participate
(b) attracting sufficient patient numbers to remain viable
(c) uncertainty regarding wider policy environment and nature of ‘competition’ in the new NHS that ‘restricts
opportunities to adapt and refine the innovation to improve its fitness for purpose’ (see Greenhalgh et al, 2005;
p.9)
Typical pattern of assimilation process in
organisations
Outline business case for capital funding; building/renovating facilities; recruitment; securing ‘buy-in’ from key
staff in ‘host’ staff organisation and more widely from other organisations in local health economy. Often strongly
driven by project management until opening
3 Diffusion and dissemination
What is the nature of the networks through which
influence about the innovation is likely to diffuse?
Centrally-driven organisational innovation; spread mainly via vertical networks; but also spread ‘laterally’ as
competing trusts spot opportunities and stake a claim for a place in this bit of sun
Who are the main agents of social influence and
what are they doing?
Senior clinicians (typically some are sceptics, some champions) supporting (or challenging) TCs through their
clinical networks; chief executives of NHS trusts seeking to gain agreement and buy-in from their own staff and
leaders of other health care organisations locally, sometimes senior nurses (e.g. Site B)
4 The inner conext
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Key questions Typical features of NHS treatment centres
What are the key structural features of the
organisation?
(a) size/maturity
(b) complexity/differentiation
(c) decentralisation
(d) slack resources
TCs have generally been adopted in established hospital units providing standard acute sector services, usually
large, mature, highly complex and often deeply differentiated internally (e.g. departmental and professional
‘tribalism’). The extent of decentralisation within NHS hospitals is typically limited and there are few slack
resources (although capital funding for TCs was provided centrally and NHS Modernisation Agency programme
was available to support local implementation; latterly a knowledge-sharing network, AmbiCentres International,
has been established)
What is the organisation’s absorptive capacity for
this type of knowledge? (a) skill mix; (b)
knowledge base; (c) transferable know-how; (d)
ability to evaluate the innovation
In general, a typical trust should have the clinical expertise and capital projects experience to initiate and plan a
TC. However, many trusts will have limited ability to manage the later necessary organisational change process
and evaluate the innovation (despite the fact that most hospitals are trying new things all the time!)
What is the organisation’s receptive context for
this type of change?
(a) leadership and vision
(b) values and goals
(c) risk-taking climate
(d) internal and external networks
Early adopters tended to be entrepreneurial and pioneers and saw TCs as an opportunity. These early TCs often
led by senior, well-networked clinicians. As TCs have become more common the nature of the enterprise - and
experiences of early adopters - have typically led to scaling back of original ambitions and more risk-averse
leadership from senior managers in ‘host’ trusts
What is the organisation’s readiness for this
specific innovation?
(a) organisational fit
(b) assessment of implications
(c) dedicated time/resources
(d) broad-based support
Very variable between trusts. Generally high and basic premise of separating elective and emergency work is
commonly accepted as a ‘good idea’. Implications for training, reconfiguration of services within trust as a whole
generally not well understood. Dedicated management and clinical time a ‘must’ and generally available. Support
has been mixed – some parts of organisation see TC as a threat (e.g. trade unions); others as an inevitable,
progressive step
5 The outer context
What is the nature and influence of the socio-
political climate?
Very strongly centrally-driven; TCs central part of NHS Plan and Government’s modernisation agenda. Patient
Choice a key component. The extent to which these policy aims are supported more generally unclear. Some
hostility to any independent sector involvement with TCs and concerns regarding perceived ‘break up’ of the NHS.
The considerable confusion in public (and staff) eyes with independent sector TCs is a problem for those
Development and implementation of NHS treatment centres
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Key questions Typical features of NHS treatment centres
developing NHS-run TCs.
Are there any external incentives and mandates? Yes (e.g. national waiting time and capacity targets) as well as what is perceived in some NHS-run TCs as an
opportunity to attract revenue to their organisation
What are the prevailing norms from other
comparable (‘opinion leaders’) organisations?
Generally supportive but some concerns re clinical training implications and (see above) the perceived threat of
TCs as ‘privatisation of NHS through the back door’
6 Implementation and institutionalisation
What are the features of the implementation
process in terms of:
(a) human resources
(b) involvement of key staff
(c) project management
Typically requires (a) significant recruitment and/or training (often to new roles) and new skills in areas such as
marketing (b) essential to have broad support among senior clinicians (c) strong project management required
especially during early phases (e.g. business case, building projects). Presence of enthusiasts
(idealists/opportunists) at most trusts has been an important enabler
What measures are in place to capture and
respond to the consequences of the innovation
(e.g. audit and feedback)?
Variable. Some TCs lack a systematic approach to this although governance concerns from the ‘host’
organisations and TCs’ own desire to market their services on the basis of good outcomes data have served to
improve audit and feedback. Most TCs have well-established patient feedback surveys in place. Little strategic
assessment so far of impact of TCs on wider health economies
8 The role of external agencies
Are the developers linked with potential users of
the innovation at the development stage, and do
they share value systems, language and
meanings?
Some of the early adopters of NHS-run TCs worked with the original developers of the concept (e.g. US surgi-
centers or the Ambulatory Care and Diagnostic Centre) but later sites appear to have had less links. Little
evidence of developers within each TC linking with end users (i.e. patients). Other ‘users’ (e.g. GPs, PCTs)
sometimes little involved in the development stage of TCs but picture is mixed.
What is the capacity and role of the external
change agency (if any) to help organisations with
operational aspects of assimilation?
The NHS Modernisation Agency provided change management support and training, as well as a knowledge
sharing network, for the first few years of TC development. Regional groups were also established to support local
implementation. Responses to these initiatives were mixed. Unsure yet about the capacity and influence of
Ambicentres International
Who are the main external change agents and do
they show
(a) homophily?
It was the NHS Modernisation Agency programme managers (on behalf of Department of Health and
Government). At one level (e.g. corporate rhetoric) they do share corporate language, positive relationships etc.
At another (in terms of how TCs are framed - see Pope et al, 2006 - and also the tension between centre and
front-line) they do not
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Key questions Typical features of NHS treatment centres
(b) positive relationships and client centredness?
(c) shared language and meaning?
Does the dissemination programme follow social
marketing principles?
(a) audience segmentation
(b) assessment of target group needs and
perspective
(c) appropriate message and marketing channels
(d) good programme management
(e) process evaluation
Centrally-driven dissemination. Major problem has been poor assessment of target needs and perspective. TCs
have - in part – been imposed either directly or indirectly (as a solution to central waiting time and capacity
targets). Quality of programme management has been mixed or poor. But overall dissemination has had little to
do with ‘social marketing principles’
What is the nature and quality of any linkage
relationship between the change agency and the
intended adopter organisations?
Participation in change agent-led activities was voluntary. Moved from a national (Modernisation Agency) to series
of regional programmes over time. On the other hand, once committed to a TC and it was part of the
performance targets for the trust, this was hardly voluntary as regards the other external agency, the
Department of Health
Development and implementation of NHS treatment centres
Queen's Printer and Controller of HMSO 2007 Page 276
Appendix 9 Publications and presentations arising from this study
Publications
Bate SP and Robert G. 2006. ‘Build it and they will come’ – or will
they? Choice, policy paradoxes and NHS treatment centres. Policy
& Politics 34 (4): 651-672.
Gallivan S. 2005. Mathematical methods to assist with hospital
operation and planning. Clinical and investigative medicine 28(6):
326-30.
Gallivan S. 2006 (in press). Modelling the assignment of outpatient
examination rooms. The proceedings of the 31st meeting of the
European working group on operational research applied to health
service.
Gallivan S and Utley M. 2005. Modelling admissions booking of elective
in-patients into a treatment centre. Institute of Mathematics and
its Applications Journal of Management Mathematics 16: 305-315.
Pope C, Robert G, Bate SP, le May A and Gabbay J. 2006. Lost in
translation: a multi-level case study of the metamorphosis of
meanings and action in public sector organisational innovation.
Public Administration 84(1): 59-79.
Utley M, Gallivan S and Jit M. 2005. How to take variability into
account when planning the capacity for a new hospital unit. In J
Vissers and R Beech (eds.) Health operations management,
pp.46-161. London: Routledge.
Utley M and Gallivan S. 2004. Evaluating the new diagnosis and
treatment centres in the UK. In M Dlouhy M (ed.) Modelling
efficiency and quality in health care: the proceedings of the 29th
meeting of the European working group on operational research
applied to health services, pp.125-32.
Presentations
Bate SP, Robert G, Gabbay J, Pope C and Le May A. 2004. A new
design for local treatment? Early findings from a study of NHS
Treatment Centres. Third national Service Delivery & Organisation
conference: delivering research for better health services. London.
Gallivan S. 2005. Scheduling outpatient clinics, a rooks tour and the
Birkhoff von Neuman theorem. Paper presented to the 31st
meeting of the European working group on operational research
applied to health services. Southampton.
Development and implementation of NHS treatment centres
Queen's Printer and Controller of HMSO 2007 Page 277
Gallivan S. 2005. International workshop on modelling health care
systems: linking operations and health services research.
University of British Columbia, Vancouver.
Jit M, Utley M and Gallivan S. 2005. Can a treatment centre reduce the
total bed requirements within a local health economy? Paper
presented to the 47th meeting of the Operational Research
Society. Chester.
Le May A, Gabbay J, Pope C, Robert G and Bate SP. 2005. NHS
treatment centres: case studies in the implementation of an
innovative policy into NHS practice. 6th international conference on
the scientific basis of health services. Montreal.
Pope C, Le May A and Gabbay J. 2006. Chasing chameleons, chimeras
and caterpillars: researching the implementation of an
organisational innovation in the National Health Service. Paper
presented to the International conference on organisational
behaviour in health care. University of Aberdeen. (Received ‘best
research paper’ prize.)
Pope C, Robert G, Bate SP, le May A and Gabbay J. 2004.
Metamorphosis of meanings and discourse in organisational
innovation and change processes: a multi-level case study of NHS
Treatment Centres. Paper presented to 6th international
conference on organizational discourse: artefacts, archetypes and
architexts. Amsterdam.
Robert G, Bate S.P, Pope C, Gabbay J and Le May A. 2005. Processes
and dynamics of identity formation in professional organisations:
longitudinal case studies of a new organisational form. Paper
presented to the 21st European Group on organisational studies.
Berlin.
Utley M and Gallivan S. Evaluating the new diagnosis and treatment
centres in the UK. Paper presented to the 29th meeting of the
European working group on operational research applied to health
services. Prague.
Disclaimer This report presents independent research commissioned by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, the NIHR SDO programme or the Department of Health. The views and opinions expressed by the interviewees in this publication are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, the NIHR SDO programme or the Department of Health Addendum This document was published by the National Coordinating Centre for the Service Delivery and Organisation (NCCSDO) research programme, managed by the London School of Hygiene & Tropical Medicine. The management of the Service Delivery and Organisation (SDO) programme has now transferred to the National Institute for Health Research Evaluations, Trials and Studies Coordinating Centre (NETSCC) based at the University of Southampton. Prior to April 2009, NETSCC had no involvement in the commissioning or production of this document and therefore we may not be able to comment on the background or technical detail of this document. Should you have any queries please contact [email protected].