In place of chaos

Following publication of NHS England’s Planning Guidance in December, four CCG leaders have agreed to give their perspectives on the planning process in their local health economies, providing insight with a series of blogs on the process of developing, and delivering, the two year and five plans in their area. In his latest blog Dr Nadim Fazlani, Chair of Liverpool CCG and chair of the NHS Commissioning Assembly CCG Development Working Group, looks at the need for change and managing transition:

Liverpool is among the most complex health economies in the country, and those of us working in the NHS in the city accept that we cannot stay as we are.

NHS planning guidance is very clear about the need for transformation and this is a real challenge to all providers. As we develop our next steps in our transformational programme the ‘Healthy Liverpool Programme‘, I am repeatedly warned about unpredictability and consequences.

This is of course one reason why change has been so difficult in the NHS, but the time has come to face up to this unpredictability. We currently have order, which is comfortable but not sustainable, and the move to disorder is inevitable.

In Liverpool, as elsewhere, we need to manage this transition between order and disorder. Let me give you an example: the planning guidance talks about 15 to 30 centres for specialised services, yet in Liverpool we have two major teaching hospitals and three specialist trusts – a nearby cancer centre is also planning a move to the city.

Given this context, what should be the principles for change and how do we make decisions here? Are we arguing for the principle that specialised services in a city as compact as Liverpool should be on one site? Planning guidance very clearly points in that direction even if we say that the reference to 15-30 is highly speculative.

Centralisation of specialist services is happening in the US as well so this is not just a UK issue. Size and scale is important and UK centres need to have scale locally and link together nationally in networks.

I believe the clinical arguments are also compelling in terms of 7/7 working, teams large enough to allow professional development and support. Similar arguments could apply to general practice and maybe we can speak aloud the heresy that we are now at the end of the largely single/two site small provider model. Add to that interdependencies and multi-disciplinary nature for critically ill medical/surgical patients, and there is compelling argument towards a single site in Liverpool. These sorts of discussions will be happening across the country.

This is not the first time the health system has undergone a transformational change; the very first was at the foundation of the NHS in 1948. That year saw a much bigger fiscal challenge than now and the unpredictability of moving into a new system (the NHS) was extremely high.

I will quote from an essay by Nye Bevan ‘In Place of Fear A Free Health Service 1952’, which sounds very topical: “They create a chaos of little or big projects, all aiming at the same end: assisting the individual in time of sickness.”

Surely he could not have had in mind 211 CCGs, 151 Health and Wellbeing Boards, 27 Area Teams and the many providers? And while we are looking at sentiments expressed by Nye Bevan, his assertion that: “The essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability and that wealth is not advantaged”, is still as true now as it was then. If we don’t hold on to this principle then we will not improve health outcomes.

The second big change came in 1962 when Enoch Powell, then minister of health, published the Hospital Plan for England and Wales. It served as a framework for the development of hospital services in the decades that followed, leading to the building of many new hospitals and the refurbishment of others. At the heart of this framework was the district general hospital, designed to provide a comprehensive range of inpatient and outpatient services to populations of 100,000 to 150,000. District general hospitals have formed the backbone of NHS hospital care ever since.

The time for changing the district general hospital is here and this applies to Liverpool as well. This was foreseen in Enoch Powell’s famous water tower speech and I quote: “It would be quite unrealistic to attempt to state what is intended, and what is not intended, by way of hospital provision in the 1970s and not to spell out…all that this implies in terms of care outside the hospitals. I will go so far as to say that a hospital plan makes no sense unless the medical profession outside the hospital service will be able to progressively accept responsibility for more and more of that care of patients, which today is given inside the hospitals. It makes no sense therefore unless the medical profession outside the hospital service can be supported in this task by a whole new development of the local authority services for the old, for the sick and for the mentally ill.”

So what should be the features of the new generalist hospital? Co-location is very helpful for specialised services but most acutely unwell patients need good generalists (in or out of hospital) and mostly people need good general practice and joined up care. Our system needs to be reshaped to drive value for patients rather than support institutions, including both in hospital and out of hospital care, linked with a community provider and delivering good wrap around generalist services. It’s about shifting the balance back to what generalist hospitals should be, the concept for which Enoch Powell laid the foundation in 1962.

The Hospital Plan was a ten year programme but took twice as long and costs were vastly underestimated. I would argue that the challenges of 1962 were greater than they are now; it was a time of change and while it was the best of times, it was also the worst of times.

I will give you an example of this from Liverpool: The Royal Liverpool Hospital was one of the new hospitals created as a result of Enoch Powell’s plan. It opened in 1978, delayed and vastly over the original cost, to replace three city centre hospitals. In a sign of the times, a completely new Royal is currently under construction and will open in 2017. This will not just be a shiny new building but a centre sustained by changes in out-of-hospital care. I take you back to a quote from the water tower speech: “That is why, at the earliest moment possible, I intend to call on local health and welfare authorities, through the bodies which represent them, to take a hand in mapping the joint future of the hospital and the local authority services.”

This is now finally happening in Liverpool, as elsewhere, in the shape of Health and Wellbeing Boards. Transition between order and disorder is not chaos; management of transition can happen by the whole system taking ownership, accepting unpredictability and unintended consequences. We need feedback systems which are sensitive, but with oversight to manage a transition into order not chaos.

Above all we need to be brave, embrace change and we need to do this together.

Dr Nadim Fazlani

Dr Nadim Fazlani is Chair of Liverpool CCG and has been a GP in Kensington Liverpool for the past 22 years, having worked in the NHS since 1983.

A Fellow of the Royal College of General Practitioners, he was Chair of Liverpool Health Care Practice Based Consortium from 2006 – 2011 and Chair of Liverpool Central Clinical Consortium from 2011 to 2012, before being elected as Chair of Liverpool CCG.

He has also been a long standing GP trainer and an examiner for MRCGP conducted by Royal College of General Practitioners since 2004.

In addition, he is also a performance assessor for General Medical Council, a role he has undertaken since 2005.

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One comment

  1. Dr.Syed Razvi, G P Walton Village Medical Centre ,Liverpool L4 6Tw says:

    Many Congratulations Dr.Nadim,on the anniversery of our CCG
    your bright and able chairmanwhip has enlightened our health service here,
    some simple examples of improvement like our “Phlebotomy service at Breeze hill operates from 7AM till 7PM
    Creation of Winter sessions has covered the extra demand wisely and smoothly across the Practices.
    Happy to serve the community and at your service
    A Colleague