The NHS Next Stage Review has been led locally by clinicians in each NHS region. Seventy-four local clinical working groups, made up of some 2000 clinicians, have been looking at the clinical evidence and engaging with their local communities. They have developed improved models of care for their regions to ensure that the NHS is up to date with the latest clinical developments and is able to meet changing needs and expectations.

NHS Next Stage Review Leading Local Change sets the context for these local visions and the principles which will guide their implementation.

Changing for the Better provides best practice guidance on provide clear guidance for patients, the public and NHS staff on the processes underpinning changes to acute NHS services arising from the NHS Next Stage Review.

The debate about organisational models for community provider services has been ongoing since 2005. One model being examined is that of a community foundation trust (CFT), allowing community service providers to acquire the same freedoms as acute and mental health foundation trusts.

Towards autonomy from the NHS Confederation draws on the experiences of eight CFT pilots and looks at what other organisations can learn from them. The pilot CFTs have had different experiences but some common themes emerge, most importantly the potential to bring benefits for patients.

The devolution of increased power to local NHS bodies and front-line professionals,has resulted in calls to ensure that those who take on increased responsibility are held to account. There is no clarity on how this may be achieved or the extent people want more control over how their primary care trust (PCT) spends its money.

The main political parties im to end the ‘democratic deficit’ and ensure local people have increased input on the delivery of local health care, and this will be a central theme of Professor Lord Darzi’s review of the NHS. The King’s Fund report, Should Primary Care Trusts Be Made More Locally Accountable?, makes a thorough assessment of the various options for making PCTs more accountable to their local communities.

It states that if the aim of involving the public is to give more democratic validity to the health service, systematic changes – such as giving local councillors control over PCT budgets, or electing PCT board members – would be appropriate.

However, improving the quality of services is the target, then an incremental approach would be better.  Targeted initiatives – such as citizens’ juries or enhanced Public Patient Involvement Forums – focusing on specific PCT functions may prove to be a more successful route to accountability.

An independent NHS: what’s in it for patients and citizens?  a report, from the Picker Institute, considers the potential value of independence  for the NHS from government  control from the point of view of the public, rather than politicians, clinicians or NHS management. It suggests using the BBC Charter model greater independence for the NHS from the government may offer benefit to patients and citzens if Public Value approach is applied greater by promoting mature debate over values, funding levels, and delivery options, thereby giving effective ‘authorisation’ (a democratic mandate)
to a more ‘independent’ NHS Authority. The Authority can then both be empowered to get on with the job for an
agreed period and be held to account at the national and local levels, and at the individual patient and public/citizen levels.

Public Value in this context should focus the NHS on ‘what the public values’ – in this case, what patients and the public value aboutthe NHS and its services – and on ‘what value is added to the public sphere’, that is, the creation of better health throughout society and better outcomes from care and treatment.

Why the NHS is the sick man of Europe by James Gubb of the think tank CIVITAS argues that market-based reform in the NHS is being crushed by central direction and will fail if this pressure continues. It recognises that the NHS’s ideals of universal and comprehensive health care are admirable, but suggests the delivery mechanism is not.

The report compares the NHS with health systems in countries such as France, Germany, Switzerland and the Netherlands which it states succeed in delivering much higher standards of health care than the NHS for all. The key difference between the NHS and these health systems is that the state is not cast as either the main funder or provider of health care, but effective regulator.

It suggests that rather than a tax based health system, social insurance is fundemental because it ensures the consumer - the patient - controls the purse strings, not the government and the health service is therefore much more responsive.

In each comparator country the following universal principles apply:

• All individuals are obliged to pay into a health insurance plan from a menu of insurers;

• Insurers are obliged to accept all the applicants that choose them;

• The government both defines the mandatory minimum package, and pays for/tops up for those on low incomes or with excessive health risks.

France and Germany achieve this direct from wages, the Netherlands and Switzerland through health premiums supported by subsidies for the less well off and sick.

The development and implementation of NHS Treatment Centres as an organisational innovation (summary) details how organisational and social factors influence the development and delivery of innovative models of health care. It considers the development of eight NHS Treatment Centres, which were considered as ‘models of innovation’.

• The stakeholders involved shared a common motivation to bring about improvement in patient care. The processes of development and implementation for each Treatment Centre were unique, resulting in a range of different models and variable outcomes for their continuing operation.
• The ‘innovation journey’ experienced by all was similar to that undertaken by commercial companies: running from inception through to adoption or abandonment, with some common events but also unpredictable elements to the journey.
• Flexibility is vital for successful health care innovation. Centrally driven programmes need to permit local change managers to reframe innovative models to meet local needs and priorities.
• Health care innovation cannot be introduced in a vacuum – the policy environment has a major influence on its journey. Success depends on stakeholders’ abilityto contend with such volatility

The Reform think tank have produced NHS reform: national mantra, not local reality uses recent academic studies to show that the performance of the NHS across the lifespan is well behind other countries. Improving patient care will need new investment in many areas, but taxpayer funding is (and should be) restricted in coming years. The solution is improved productivity. The report finds that the internal market has altered to favour producers rather than patients. Patient choice and independent sector treatment of NHS patients are in decline.

The report defines two scenarios:

1. Current trends will lead to the negative scenario where the NHS delivers substandard quality and access for 11-12 per cent of GDP (c.£110 billion – c.£120 billion). In this scenario key staff leave the NHS increasing its problems.
2. Alternatively reform delivers immediate access to excellent quality services at a cost of 9-10 per cent of GDP (c.£90 billion – c.£100 billion). Fundemental to this reform is an economic constitution which requires value for money and guarantees patient choice and a diversity of providers. The report believes this would deliver significant improvement within 18 months.

Key findings are:

• In 2007, seven international clinical benchmarking exercises revealed a cradle-to-grave performance gap compared to peer group countries.
• The medium term requirement is investment in many areas. Funding will be restricted given the immediate pressures of a slowing economy and longer term concerns over economic competitiveness. The NHS must redesign and improve services within a ceiling of 9-10 per cent of GDP.
• NHS reform is increasingly a national mantra rather than local reality. Primary Care Trusts, practice-based commissioning and patient choice have failed to drive significant change in the interests of patients. There is no level playing field for independent sector provision. The short-term focus of policy from the Department of Health has prevented a focus on the medium term challenge.
• The return of the service to financial surplus does not signify a better position in which investment can take place. The surplus is due to a temporary combination of the last years of major funding increases and a pause in centrally-prescribed cost increases.
• Current trends therefore point to the scenario of decline. This could be altered with an economic constitution for the service that defines the duty to create value at all levels.

Learning from investigations from the Healthcare Commisson highlights the following issues that have been consistently highlighted as a result of their investigations.

• Leadership and management: Poor leadership was a problem in nearly all of the investigations carried out by the Commission.

  Some boards had been focused on mergers or targets at the expense of their broader activities.

  Lack of continuity in leadership was a problem in some trusts, where frequent changes in management were a factor in poor care. Bullying and harassment by managers was a factor in two cases investigated. The Commission found there was a fine line between promoting change vigorously and bullying.

  Investigations often uncovered a breakdown in leadership and management, with a lack of clarity on responsibilities from board to ward. Poor teamwork, either between management and clinicians or between clinicians themselves was another common factor in failings.

• Use of information: The Commission was surprised that most of the trusts investigated did not have adequate systems in place to routinely inform the board of trends or potential problems. Board members must assure themselves about the quality of services for which they are responsible and need data to do this professionally.
• Mergers and restructures: Seven of the trusts investigated had recently undergone mergers or significant organisational change. The message from the Commission’s investigations is that where significant change is taking place, the management task should not be underestimated.
• Safeguarding vulnerable adults: Poor understanding of adult protection procedures and responsibilities was a serious problem in the two investigations into learning disability services and also a number of interventions in trusts. The Commission said staff need good training to understand their crucial role in protecting vulnerable adults.
• Poor care on general wards: When its investigations looked at acute hospital care, the Commission noted that care on general wards fell well below the care provided on specialist wards. Older patients were most at risk as they were often most dependent on good nursing care. The Commission will monitor this aspect in future investigations to identify whether this is an emerging common theme.

Improved Health System Performance Through Better Care Coordination (Health Working Paper No. 30) from the OECD attempts to assess whether–and to what degree–better care coordination can improve health system performance in terms of quality and cost-efficiency.

Local planning guides for premises Two new guides are available to help the NHS and local planning authorities work together. One of the guides is written for NHS staff explaining town planning in England, the other is for local planning authorities explaining the NHS and how planners can impact on it.

• A guide to town planning for NHS staff
• A guide to the NHS for local planning authorities

Caring for Vulnerable Babies: The reorganisation of neonatal services in England (Executive Summary) considers if the reorganisation of neonatal services in England has helped improve care for premature and low birth weight babies with fewer babies travelling long distances for suitable treatment. The National Audit Office in it find that further improvements to the service are being limited by shortages in nursing staff, a lack of cots in the right place at the right level of care and a lack of widespread specialist 24 hour transport. They also provide a comparison with international neonatal services via RAND Europe: The provision of neonatal services and the Survey of Neonatal Units in England by the National Audit Office upon which the report is based.

Every year around 10 per cent, or 60,000, newborn babies require some form of specialized neonatal care. And these numbers are increasing, up 5 per cent between 2005 and 2006, due to an increase in the proportion of women with high risk factors such as high or low maternal age, obesity, ethnic origin, deprivation and assisted conception such as IVF. In 2006-07, some £420 million was spent on running the 180 neonatal units in England, which are organized into 23 managed clinical networks.

A number of improvements since the Department announced the reorganization of neonatal services into networks in 2003 are identified. There has been a reduction in long distance transfers of mothers and babies, with only 3.4 per cent of babies across England admitted to units outside of their network. Overall, 17 networks are meeting the target to treat babies within their network and the consistency, communication and co-ordination of care within and between the networks has improved. The number of cots has also increased from 3,243 to 3,521. Neonatal units have made strides in considering the needs of parents and involving them in their babies care. Parents are mostly very happy with the specialist care and expertise their babies receive.

In 2005, England’s neonatal mortality rate was 3.5 deaths per 1,000 live births, similar to other developed countries. But the report found that this figure masks wide variations across the country. The South West Midlands had the highest mortality rate of 4.8 deaths per 1,000 live births, compared to Surrey and Sussex with 1.8 deaths per live 1,000 births. More work is required to determine the contribution that different socio-economic, ethnic, demographic, cultural and service factors are making to these variations in mortality rates.

The report also highlighted shortages in the numbers of neonatal nurses. On average, each unit had nearly three nursing vacancies for nurses qualified in neonatal care. Only half of units met the British Association of Perinatal Medicine (BAPM) professionally developed standard for high dependency care of one nurse to two babies, and only 24 per cent met the standard for intensive care of one nurse to one baby. The vast majority of level three (intensive care) units, which require a 1:1 ratio of nurses to babies for the whole unit, did not meet the standards for intensive care.

Cots for the right level of care are not always available, resulting in units having to close and babies being cared for in the wrong places on occasions. On average, each unit had to close to new admissions once a week, the most common reasons being a lack of cots or skilled nursing staff. Nearly a third of units had to care for a baby who should have been transferred to a higher level of care and just over half looked after an improving baby who was ready to be transferred but could not because a receiving cot was not available. In 2006-07, nearly a third of neonatal units operated above the BAPM recommended occupancy rate of 70 per cent and three units operated above 100 per cent. High occupancy rates could have consequences for patient safety, for example due to increased risk of infection or inadequate levels of care.

Neonatal transport is an essential element of networked neonatal care, with all bar one providing some form of specialist transport during day time working hours, but only half of networks providing specialist transport services 24 hours a day seven days a week. Few transport services have separate staffing arrangements from the clinical inpatient services meaning that staff have to leave the unit to accompany a baby on a transfer. Three quarters of units experienced delays in moving babies and 44 per cent believed that care was compromised as a result.

The report concludes that the cost of neonatal services as a whole are not fully understood and there is a mismatch between costs and charges. Also charges per day for an intensive care cot varied from £173 to £2,384. The reorganization of care into neonatal networks has improved the co-ordination and consistency of services pointing to increased effectiveness, however there is still capacity and staffing problems and a lack of clear data on outcomes. In addition, the variable financial management information makes it difficult to judge the economy and efficiency of the service.

The NAO recommends that NHS and Foundation Trusts need to improve their financial management information. Commissioners, in conjunction with networks and Strategic Health Authorities, should commission all neonatal care services together and in particular examine the relative cost-effectiveness of the different transport options currently in place. In addition, NHS and Foundation Trusts should develop a targeted action plan to address neonatal staffing shortages.

Social enterprise in the NHS - recent years have witnessed great changes in the accountability of different parts of the NHS as alternative providers have become an increasingly visible part of the healthcare landscape. Social enterprise is the latest delivery model to be championed by the Government as it looks to extend diversity of provision and competition within the NHS in general, and within primary care in particular. This report from Durham University commissioned looks into the impact of social enterprises in primary care, and the results provide a timely analysis of the wide variety of organisations characterised as social enterprises, and their approaches to involving staff, public and patients.

For latest information about ‘Our NHS, Our Future’ (aka the Darzi Review) and stakeholder engagement.

With the press full of stories about a potential snap election it’s probably a good time to read the Conservatives recently produced Restoring pride in our public services which forms part of a range of reports to inform policy making.

Apologies for the title but sometimes you just have to pay homage to the Psychedelic Furs!

NHS Estates projects are flavour of the month in Liverpool so it’s timely that the Department of Health issue two pieces of grey literature to support the planning process.

The Guide for the NHS aims to

• outline the town and country planning system in England at regional and local level with reference to issues specific to the NHS
• explain the correlation between planning and health, and
• encourage NHS organisations to get involved in the planning process.

A guide to town planning for NHS staff

Meanwhile for Local Authorities their guide gives local planning authorities an overview of the NHS in England. It outlines the key principles of public health; identifies the wider determinants of health and how planners impact on them; and points to how local planning authorities can interact with NHS organisations to deliver sustainable health and social care services.

A guide to the NHS for local planning authorities

The Academy of Medical Royal Colleges have just published Acute Health Care Services - Report of a Working Party, a piece of grey literature commissioned by the Department of Health, that backs proposals to reconfigure specialist services such as paediatrics and obstetrics. It says that centralising services that deliver complex treatment results result in better outcomes.