Rapid Responses to:

EDITORIALS: Chris Ham Turning around NHS deficits BMJ 2006; 332: 131-132 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Turning around NHS deficits

Hilary G Pickles   (24 January 2006)

Who says there are surplus hospital beds?

Peter G. Davies   (27 January 2006)

NHS deficits and turnaround teams – Every little helps

Padmanabhan Badrinath, Peter M Bradley   (27 January 2006)

Deficits not for turning

David Churchill   (29 January 2006)

Turning around NHS deficits 24 January 2006
Hilary G Pickles, Director of Public Health Hillingdon PCT, 97 High Street, Yiewsley, UB7 7HJ Send response to journal: Re: Turning around NHS deficits	Chris Ham1 believes the turnaround teams from the private sector will find it difficult to deal with NHS deficits. The solution he describes involves reducing spare capacity, increasing performance, and fully engaging clinicians. These measures, aspects of the failure regime for hospitals2, have some chance of success in provider organisations. The position for PCTs in deficit is even more difficult. It is likely to be even more alien to the expertise of those now being bought in from the private sector as recovery teams. PCTs are largely commissioning organisations and do not have direct levers to reduce acute capacity, even when it is recognised not to be affordable. Directly provided services form only a small proportion of PCT spend, and are needed to help reduce hospital activity. Were local hospitals to increase their efficiency, say by reducing length of stay, this exacerbates the problem for PCTs, unless those freed up beds are closed rather than used to suck in more income under payment by results. GPs are the clinicians who most need to be engaged by PCTs, but they cherish their independent status. It takes exceptional leadership to persuade them to act outside their direct interests in demand management, in advance of any of the benefits promised for them from practice based commissioning. There is little infrastructure in PCTs to downsize. Deficits of the size now seen in some PCTs would be dealt with by bankruptcy in the private sector, or increased long-term borrowing, neither of which are available to PCTs. Many chief executives believe the current difficult financial situation is generated by government policies, rather than local incompetence3. In these circumstances, private sector recovery teams have an exceptional and perhaps impossible task before them3, and especially in PCTs. 1. Ham C Turning round NHS deficits BMJ 2006; 332: 131-132 (21 January) 2. Palmer K. How should we deal with hospital failure? Kings Fund 2005 3. News story. The winter of discontent: chief execs tell their story. HSJ 19 Jan 2006 10-11 Competing interests: Hillingdon PCT is declaring one of the biggest projected PCT deficits for 2005/6
Who says there are surplus hospital beds? 27 January 2006
Peter G. Davies, GP Principal, Keighley Road Surgery, Illingworth, Halifax, HX2 9LL Send response to journal: Re: Who says there are surplus hospital beds?	Ham's editorial (1) is a clear summary of the N.H.S.’s current financial plight. However in his fourth paragraph he (whether wittingly or unwittingly) illustrates a gulf between health economic and medical thinking. There appears to be a specific belief in health economic circles that there is overprovision of beds in acute hospital settings. As a doctor I do not share this belief. When I admit acutely ill patients I see no evidence of oversupply of acute beds. Instead I am often asked to delay the admission or deflect it to A+E first. The psychiatrist tells me that he can only admit patients if they are homicidal or suicidal. The phenomenon known as bed blocking does not speak of overprovision of care in hospital, intermediate or residential care settings. All these examples speak of lack. I challenge Professor Ham to show me which patient specifically is currently being overprovided for in any NHS bed. Roemer’s Law that a bed created is a bed filled is a reflection of the fact that there is still much unmet need for healthcare. Indeed one of the commonest research findings is that “this disease is under treated or diagnosed in primary or secondary care and more time/money/education should be put into it.” This unmet need is a consequence of the icebergs of symptoms and disease. (2, 3) The NHS should be gearing up to meet unmet need. Instead it is currently being downsized and fragmented, whilst expectations of it are being upsized. The attempt by the government to sustain it solely from taxation is falling apart. In 2002 I asked what exactly would be bought by increased NHS funding. (4) In 2006 we can see that little has been bought, and much wasted. 1. Ham, C (2006) Turning around NHS deficits BMJ 332; 131-2 2. Hannay, D.R. (1979) The symptom iceberg A study in community health. London: Routledge and Kegan Paul 3. Last, J (1963) The Iceberg: completing the clinical picture in general practice Lancet ii 28-31 4. Davies, P (2002) What exactly is being bought with this gold? BMJ 325: 101 Competing interests: None declared
NHS deficits and turnaround teams – Every little helps 27 January 2006
Padmanabhan Badrinath, Consultant in Public Health IP33 1YJ, Peter M Bradley Send response to journal: Re: NHS deficits and turnaround teams – Every little helps	Dear Editor, The editorial (1) by Chris Ham is timely and relevant as there has been considerable media and public interest in the current financial health of the NHS and the government has announced how it will be tackling the issue. Ham poses an interesting question “whether the private sector will succeed where the NHS has failed remains to be seen”. Turn around teams (TATs) are not a new phenomenon in the NHS. For example, the NHS clinical governance support team has developed a framework (2) based on organisation theory incorporating the “everyday experience” of frontline staff and implemented this framework as a part of organisational turnaround interventions to support zero star organisations. The difference this time of the current TATs is that they are addressing a specific failure – inability to achieve financial balance. NHS public enquires over the years have identified (2) five explanations for failure: inadequate leadership, systems and process failure, isolation, poor communication and disempowerment of staff and service users. What does previous research show? Fulop (3) undertook a study funded by the NHS confederation to identify the markers for failure and the approaches used to turn around NHS organisations. Fulop’s conclusions might be relevant in the new era of private sector driven turnarounds. According to Fulop (3) “organisational turnaround in complex health care organisations takes time, possibly longer than in non-professionally dominated organisations, and its sustainability in the long term is questionable”. The Finance Director at the Department of Health has just submitted his report to the Secretary of State for Health on the financial turnaround in the NHS (4). In the report he has summarised the conclusions of the TATs. For some organisations these are “1) the capability of the management was inadequate to deal with the challenges of their current financial position 2) the quality of information would impede the turnaround process 3) In some cases the Strategic Health Authorities were allowing unproductive behaviour between trusts and PCTs”. This may imply that any help and support to the management team would be helpful in their efforts to achieve financial balance. The TATs have also graded the clinical and operational issues of the visited NHS organisations using a traffic lighting system as Red, green and amber. It is hard to tell whether TATs will succeed in professionally dominated complex health care organisation with competing sub-cultures. However our local experience (5) already shows that when TATs identify good practice and provides feedback this lifts up the morale of NHS managers and frontline staff as has happened in our own organisation. According to the newspaper item (5) “The Suffolk West PCT received the highest possible ranking from a management consultancy turnaround team which was scrutinising the finances of the cash strapped body. The report concluded the PCT has a ‘robust and effective’ financial recovery process that is delivering the plan and does not need external support”. References 1.Hewitt Announces Action To Turnaround NHS Finances. DH pressrelease, 25th January 2006. http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4127292&chk=HDOR9C Last accessed 27th January 2006. 2.Glanfield P, Bevington J, Appleton L. Getting to the heart of what matters. Page 20-23. http://www.executive.modern.nhs.uk/pdf/NHS-InView- december2004.pdf Last accessed on 27th January 2006. 3.Fulop N. Organisational turnaround. Lessons from a study of ‘failing’ health care providers in England. http://www.rhul.ac.uk/Management/News-and-Events/seminars/Naomi%20Fulop%20 -%20abstract.pdf Last accessed on 27th January 2006. 4.Financial turnaround in the NHS. Department of Health. http://www.dh.gov.uk/assetRoot/04/12/71/88/04127188.pdf Last accessed on 27th January 2006. 5.Top score for health trust. Suffolk west PCT has a ‘robust and efficient’ financial recovery process. East Anglian Daily Times, Saturday, December 24, 2005. Dr.P.Badrinath Consultant in Public Health Dr.Peter M Bradley Director of Public Health Suffolk West PCT, Thingoe House, Cotton Lane, Bury St Edmunds, Suffolk IP33 1YJ Competing interests: The authors are employed by a PCT, which is in financial deficit and was visited by a turnaround team in December 2005, which reported the PCT’s position.
Deficits not for turning 29 January 2006
David Churchill, Consultant Obstetrician & Associate Medical Director. The Royal Wolverhampton Hospitals NHS Trust, New Cross Hospital, Wolverhampton, WV10 0QP. Send response to journal: Re: Deficits not for turning	Ham is right to be sceptical about the private turnaround teams1. Personal experience with “franchising”, a similar process, has led me to a similar position2. There are 3 main reasons why faith in their abilities is misplaced. Firstly the private sector under-estimate the wider responsibilities of hospitals. Unlike the private sector, public institutions are not free to simply disinvest in non-profitable areas. Accountabilities run wider than just the organisation itself, into the wider local community. Also the demands of transparency and the burden of governance are more stringent. Secondly the private sector does not genuinely comprehend the complexity of medical care. Like chaos theory, one small action within the organisation can have a myriad of unforeseen consequences for the whole system. Thirdly, there are major structural problems with NHS finances and organisation. Resources are not distributed with equanimity at the national and health authority level. Only selfless political leadership will resolve these problems. Ham is right to point out that the solution lies with the full engagement of clinical teams. However the Department will have to rebuild confidence in clinicians and managers. It may be unpalatable to hear, but after years of being blamed for the failure of the NHS, managers and clinicians at the front line have distaste for all things central. It is time to stop trying to remodel the NHS in the mould of the private sector, take stock of the successes over the last 60 years and reaffirm its founding principles. Then the experience of the NHS workforce should be brought to bear on the problems of the NHS. Local teams must be allowed to take risks and politicians should have the courage to support them, even in the face of opposition from the public and vested interest groups. 1. Ham C. Turning round NHS deficits. BMJ 2006; 332: 131-132 2. Churchill D, Zissman B. The facts about franchising at Good Hope Hospital. (letter) BMJ 2003; 327: 412. Competing interests: None declared