Sustainability and Transformation Plans (STPs) are very much on people’s minds at the moment, as health and care systems consider their ‘route map’ for delivering the vision set out in the Five Year Forward View. New organisational models in the Vanguard Programme are embryonic and there is much interest in how they will develop.
The Foundation Group model is one such development intended to address the limitations of what is essentially the legacy of Enoch Powell’s (then Minister for Health) 1962 Hospital Plan for England and Wales. This plan announced that district general hospitals, serving populations of 100 – 150,000 populations would be the mainstay of NHS provision. Although a commendable vision for 50 years ago we are still working within its architecture which does not work for today’s complex health problems and so a new blueprint needs to be developed.
In 2014 I had the privilege of heading up the Review led by Sir David Dalton from Salford Royal NHS Foundation Trust, which examined the future sustainability of the provider sector and made recommendations regarding the adoption of seven organisational forms. The most notably different was the Group model.
Today, Guy’s and St Thomas’ (GSTT), in partnership with Dartford and Gravesham NHS Trust (DGT), is one of the first aspirant Group trusts in the Vanguard Programme. To provide some context, (GSTT) is a £1.3bn Teaching Hospital with almost 15,000 staff; serving a local population of 615,000 across Lambeth and Southwark, although 60% of our work is specialist. In comparison, DGT is a medium sized hospital in Kent, serving a population of 340,000, with £215m turnover and 2,500 staff. Although DGT has been recognised for its clinical quality - having consistently won a Top Hospital award, it is struggling financially with a Public Finance Initiative (PFI) deal which still has another 18 years left to run. Trying to ensure they have a viable future has been the priority for the DGT Executive Team for the last five years. However, a failed merger with Medway FT in 2013, meant that a different solution was required.
In June 2015, we began the first tentative steps of our Vanguard journey by testing whether there were strategic, clinical and financial synergies between the two organisations that could be enhanced through a different organisational form. We were seeking to develop a model for creating a sustainable local hospital without the need for merger or acquisition. It has been a challenge as we were starting from scratch, unlike some of the other Vanguards that had been working towards their models for some time.
Partnership working can be tricky at times and the asymmetry of our organisations sometimes compounds these issues. However, both organisations are committed to the potential that this Vanguard offers and so things have moved at pace and we are now five months into the implementation process. So, one year on from our initial meeting last June, I thought I’d share some of our lessons learned.
Be clear on the vision – trying to make sure we are speaking a common language is crucial. Taking the time to agree your vision up front and understand the definition of success for both organisations individually as well as the partnership is an important mechanism to test how decisions will progress the achievement of the vision.
Partnership working requires an investment of time and effort – building relationships from almost scratch, as we have done, can be difficult to navigate. We have spent a lot of time being clear about the principles that underpin our relationship and have tried to spend time in each other’s organisations to build up trust and mutual understanding to enable us to have difficult conversations. Ensuring the partnership is working well is a key plank to ensure long term success and it needs to be secure enough to withstand key personnel changes.
Design the change both top down and bottom up – as ‘form follows function’ we are working within three clinical specialities – cardiology, vascular and paediatrics – to develop the clinical models that the organisational form will need to support. There is a temptation to design the organisational form first followed by the clinical pathways, however we felt that in order to optimise the vision of developing local, sustainable health services, we needed to ensure the clinical model could be enhanced and patient outcomes improved.
Be prepared to fail – this is a Vanguard Programme, the ethos of which is to ‘hot house’ a few areas to be courageous and design new models of care to address the challenges facing the NHS. Our Vanguard is working on the premise that the Group model will support the ability to share scarce workforce resources; standardise pathways to improve clinical outcomes and reduce the financial deterioration of DGT. We are aiming to design a replicable model for other small local hospitals, particularly those in rural, coastal or challenged health economies. However until we can understand the cost implications of the Group model, we are not absolutely sure that this is going to work. We have to have courage both to undertake the work in the first place but also the courage to stop if we think it is not the right answer or is not going to address the initial problem of DGT’s financial deterioration.
Being a Vanguard site is both incredibly exciting, challenging and at times daunting, as we are simultaneously trying to design a new and novel organisational form for the NHS whilst ensuring that we continue to deliver the day job in increasingly difficult circumstances. However, if we can get it right it could be a game changer for the NHS, and we could develop a new blueprint that will secure the next 50 years of the NHS.
About the author
Sarah Morgan is the Programme Director for the Foundation Healthcare Group Vanguard and the Director of Organisational Development for Guy’s and St Thomas’ NHS Foundation Trust
Sarah was the Head of the Dalton Review for the Department of Health in 2014