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3 September 2014

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Working together and organisational change are key themes of the Dalton review
The magnifying glass is well and truly hovering over NHS provider models as they come under scrutiny in a way they have not done since the inception of foundation trust status. 

Working together and organisational change are key themes of the Dalton review
The magnifying glass is well and truly hovering over NHS provider models as they come under scrutiny in a way they have not done since the inception of foundation trust status. 
Much of this is down to Sir David Dalton, the long standing chief executive of Royal Salford Foundation Trust, who has been asked by Secretary of State for health, Jeremy Hunt, to look at how provider models in the NHS could be changed, to ensure clinical and financial stability across the system.     
Though the basis of the Dalton review is around the provider model his team has recently asked for increased contributions from other sectors including commissioners. Though not due to report until October, the strength of government support for the review would suggest organisational change is inevitable. What could this mean for clinical commissioning groups (CCGs)?
Liverpool CCG chair Dr Nadim Fazlani is sceptical about the breadth of potential change. “The idea of a hospital chain is an interesting concept. But the provider/commissioner relationship we have is not that which exists in other countries. Such moves will require a change in legislation,” he points out.
Dr Fazlani says he unsure there is enough support for such moves. “Why would a successful trust take over a struggling trust that is geographically distant? What is in it for them?”
Co-chair of the NHS Clinical Commissioners leadership group and Bassetlaw CCG chair Dr Steve Kell says that although CCGs welcome trusts looking at ways to become safer and more sustainable, it would be vital for commissioners to be involved at an early stage.
“We have the number one rated health system in the world, so we need a clear case for any change. And organisational change alone should not drive service change. It has to be about patient care; anything else is a distraction from core business.”Dr Kell is not alone in being concerned that such moves could distract providers or lead to management structures being diluted. Deputy director of policy at think tank The King’s Fund, Candace Imison, who has recently co-authored a report on possible future organisational models for the NHS, agrees that any such move could not be attempted without ensuring there was strong management in place. 
“From talking to US providers [of hospital chains] it was very clear that a hospital [that is part of a chain] needs to retain local leadership and relationships. Whatever happens to the provider model will need dedicated local clinical, medical and management leadership throughout – not just one heroic leader at the top.” 
Membership body NHS Confederation policy director Dr Johnny Marshall agrees local leadership will be crucial. 
“People with the necessary autonomy and freedoms to have local relationships have to be there regardless of the operational structure,” he says. “The critical thing here is not to look at acute providers in isolation.” West Hampshire CCG chair Dr Sarah Schofield points out that as local relationships are often longstanding between GPs and the hospital consultants they commission, such clinical relationships will continue regardless of which operational structure is in place.  
However, Ms Imison adds that she increasingly sees how relationships in the system can develop not just within an organisation but across organisational boundaries. 
“We have to ask what the system is doing to reinforce that. And increasing integration between primary and secondary care raises the question –where’s the equivalent strategy for leadership in primary care?”   
Working together is a theme that comes up repeatedly from commentators who stress it is the key to working through any organisational change for commissioners and providers alike.
“Place-based commissioning and delivery is the local health community working together. Any new model of provider has to fit into this,” says NHS Clinical Commissioners director Julie Wood, who adds that the Dalton review will have to address issues such as fixed costs that currently stop health economies from having the freedom to think differently. 
“When we get commissioners and providers together there are tensions but what brings them together is the population they feel responsible for. How they are measured and the mechanisms by which they are paid then distract from that purpose,” agrees Dr Marshall.  
There are concerns the prospect of ever larger providers could be increasingly dominant over some CCGs, many of which commentators believe are too small and too under resourced to be capable of efficient commissioning. CCGs who work largely with a single provider could be especially vulnerable. 
Dr Fazlani believes that this could be countered by more CCGs working together, in the further development of networks many have already established.   
But Ms Imison warns of the disparity of the quality of information available between commissioners and providers, which can lead to an unequal balance of power. 
“There are already challenges for many commissioners. They just don’t have the manpower in place to deliver – and many CCGs also have a significant reduction per capita expenditure funding – but many small commissioners are commissioning very large providers.” 
Meanwhile, CCGs bruised by ongoing battles with local populations furious about any proposed service changes may dread the prospect of having to help sell such moves. But both Dr Schofield and Dr Rod Smith, chair of North and West Reading CCG and of the Berkshire West Confederation of CCGs, believe local populations actually care very little for who is running services. 
Having witnessed the recently completed takeover of one Berkshire trust by another, (Heatherwood and Wrexham Park Hospitals foundation trust by Frimley Park foundation trust), Dr Smith says CCGs should work to cultivate whichever relationships are most beneficial for its local health system.   
“Further organisational change is inevitable,” says Dr Smith. “I don’t think a local population will care, or worry about it, as long as a service is safe, and it is local.” 
And there is the crux of this issue. Local populations also want their services to be there, unchanged. Any service changes made for the sake of clinical need and patient safety need to be carefully explained. 
“People are very attached to the physical nature of what they consider to be their NHS, and get very indignant about any potential change to that,” says Dr Schofield. “If there are to be service changes we must talk about the positives, long before anyone starts talking about closures.”  
The Dalton Review 
Royal Salford foundation trust chief executive Sir David Dalton has been asked by health secretary Jeremy Hunt to conduct a review into possible new organisational forms, “to ensure clinical and financial sustainability across the system”. Of particular interest is the ways in which high performing trusts could be encouraged to take charge of struggling ones, what incentives could be put in place and which issues currently prevent this from happening more frequently. 
Launched in February, the review’s panel members include the heads of regulators the CQC and Monitor, five chief executives from other highly thought of foundation trusts and the heads of membership bodies such as the NHS Confederation, Mental Health Network and Foundation Trust Network. The heads of two private providers – Circle and Care UK – are also on the panel.  The review is due to report in October. 
More details of the review can be found online. Individuals and organisations wishing to contribute to the review should contact the Department of Health

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