A chain reaction? Anticipating the Dalton review

The Danish physicist Niels Bohr allegedly observed that it’s hard to make predictions, especially about the future. Hard but not impossible: the Five Year Forward View has already made a big impact on the debate about the future of the NHS in England, so it’s a fairly safe bet that it will come to be seen as a landmark report in health service history.

Included in the Forward View is a sneak preview of another report. Sir David Dalton – Chief Executive of Salford Royal NHS Foundation Trust and a governor at the Health Foundation – has been reviewing how leading NHS hospitals can expand their reach to benefit more patients. Sir David’s review has looked at organisational models in other health systems for inspiration, one of which is where a single organisation manages several hospitals, potentially in different parts of the country. This model – described as a hospital chain – is one of several already endorsed by the Forward View.

Chains are, of course, a familiar feature in the world outside health care. Many of the goods and services we use – food, clothes, electrical goods, financial services, etc – are primarily supplied by outlets that are part of a chain. Within health care, many pharmacies and opticians are also part of chains. At engagement events on the Dalton review – some of which I attended as a member of the Department of Health’s review team – some people asked whether the NHS itself is already a chain. That largely depends on resolving the longstanding question of whether the NHS should be treated as a single organisation or a system of autonomous providers, an issue highlighted in our briefing on the NHS Bill recently published by Clive Efford MP.

A common feature of chains in any sector is the drive to achieve consistent quality. McDonald’s is famous (or infamous, depending on your point of view) for offering a consistent product from thousands of different locations around the world. That doesn’t happen by accident: chains tend to determine the processes and outcomes all outlets are expected to achieve and then work to minimise unnecessary variation from those common standards. Enforcing standard practices has to be balanced with some scope to adapt to local circumstances and space to innovate. Successful innovations are adopted into standard practices and rapidly spread throughout the chain.

Health care is obviously more complex than hamburgers, but the possibility of using the operating principles of chains has already been highlighted by, among others, Atul Gawande. The notion of defining best practice, reliably delivering it at scale and rapidly spreading proven innovations is clearly relevant to the NHS.

The Forward View suggests smaller acute hospitals could come together in chains to help them to remain viable without centralising clinical services. It mentions the potential economic benefits of chains, which could include centralising back office functions like HR (which would also logically include some dedicated quality improvement capability) and pooling buying power to reduce costs. The evidence on achieving economies of scale through hospital mergers is not particularly promising, but the Dalton review may also highlight the potential for chains to drive improvements in quality.

The Helios Group in Germany, for example, has used scale and standard processes for reviewing and benchmarking outcomes to improve quality across its chain of over 100 acute hospitals. Monthly quality reports, broken down by hospital, are sent to all lead clinicians and hospital managers in the chain. A group of senior clinicians reviews the data and undertakes an internal peer review if any hospital gives cause for concern, resulting in an action plan for supporting the hospital to improve. Hospitals with worse than average mortality rates were found to have made significant improvements on all measures within three years of acquisition by Helios and exposure to their quality system.

None of these elements are new to the NHS. Defining best practice, benchmarking performance and learning from peer review are all familiar tools. But the hospital chains I spoke to as part of the Dalton review all suggested that using these tools became faster, easier and more effective within a single, large organisation than working through a network or collaborative. If that proves correct, the findings of the Dalton review could have a significant impact on the future shape of NHS services, albeit probably with fewer column inches than the Forward View.

It’s a big ‘if’, of course, and the acid test for all the models set out in the Dalton review will be making them work in practice. The review's interim report stressed the importance of finding solutions that work locally, with the role of the centre being to enable rather than dictate change.

But the centre retains an important role in providing political air cover and thinking space for the people trying to design better local solutions and make them work. Like any large-scale change, that will require investment of time and money that may not produce immediate results. Focusing on medium-term change, like the development and implementation of new models, will also require management headroom that, according to the senior managers I’ve spoken to, is currently preoccupied with fire-fighting on issues like A&E waits. Growing concerns about long-term sustainability of providers – despite the recent announcement of more money – can be a useful spur for change, but the centre must not allow financial issues to dominate the discussion.

Will all of this be put in place? Some predictions are harder than others. 

Tim is Senior Policy Fellow at the Health Foundation,www.twitter.com/TimGardnerTHF