Redesigning hospital systems Nigel Edwards Policy Director, NHS Confederation, UK Hon. Visiting Professor LSHTM

Pressures for change - external Consumerism Workforce shortages Cost inflation Epidemiology Demography

Pressures for change - internal Increased specialisation A link between quality and volume of work Concerns about safety, in particular about small or isolated hospitals Policy to shift care out of hospital Changes in the position of hospitals in the system

Complexity of care situation All care situations Care situations ordered by complexity

Complexity of care situation All care situations Typical structure of traditional delivery system Care situations ordered by complexity

Complexity of care situation All care situations Situations handled by an overqualified and too costly system Situations handled by an under qualified or overloaded system

Pressures for change - internal Use of small hospitals for training Working hour restrictions Increased multidisciplinary working – requiring larger teams Using trainees to staff hospitals Consultants firmly based in hospitals MMC

Standard strategic responses Ignore & hope for the best Centralisation

Too slow Costly Politically tough Does not solve the problem of emergency medicine –Local access –Frequent users and social care require local links

Standard strategic responses Ignore & hope for the best Centralisation Mergers

Costly Often dont deliver or very slow Integration of different organisations very tough Dont get to the heart of some of the pressures on hospitals

Standard strategic responses Ignore & hope for the best Centralisation Mergers Market development Cost reduction & efficiency improvement

A recent strategy: Redesign Capacity and demand –Advanced access –Theory of constraints Process improvement –BPR –Leanthinking Workforce –New roles –Substitution

Key questions How do we create a sustainable model What is the role of the hospital? What is its relationship to primary care? Could changes in the way that staff work provide some new answers? Could technology assist with this?

Role Different approaches for large centres and for small and medium sized hospitals Is the hospital a facility or at the centre of the system? Component producer or responsibility for a defined population? Beds – cost centre or profit centre?

Primary / secondary care Is this division helpful any more? The role of specialists –Where specialists work –Who they work for and with Vertical integration Where do some key resources sit? –Diagnostics –A&E Social care

Specialisation and generalism Have we got the balance right? Some services need specialist centres Increase in patients with multiple diagnoses Rise of hospitalists Multi-site networks

Clinical interdependences Are the assumptions we make about these still correct? Can we provide enough locally to be able to deal with the high volume local emergencies? –Internal medicine –#NoF, Acute abdomen, etc. out of hours –Sick children Could a different approach to the way specialists work help with this?

Conclusions The hospital needs to be seen as an integrated part of the healthcare system in which it sits The most significant obstacle to change is the absence of a vision for the future which is meaningful for clinicians