Elaine Maxwell - Development in Foundation Trusts - Thursday 29 June 2017

“The only thing we can be certain about when it comes to foundation trusts is that they’re in a state of transition,” Elaine Maxwell told Care Conversation delegates. “In terms of exactly what’s going to happen, no one can be entirely sure.”

Foundation trusts had a triple aim, she said – improving the health of populations, enhancing the patient experience and reducing healthcare per capita costs. “However most healthcare systems work within some sort of insurance model, so they’re clear about what’s inside and outside the policy. It’s not like that in the NHS, so it’s really challenging to optimise a system when you don’t have that specification.”

Added to this was the enormous ‘frailty challenge’ of an aging and growing population that would need hospital care, she stressed. Half of the population had one long-term condition by the age of 55, and by 85 they had three. “But hospitals were originally set up to treat one single condition. So you could be going in to have your hernia repaired and you’ve also got diabetes and Parkinson’s – the way we’re funded is just to treat the hernia.”

Almost half of hospitals’ workload was with people aged over 65, she said. “Around a quarter of people who attend A&E are over 65, and half of people admitted to hospital after A&E are over 65. We haven’t got to grips with this issue, and that’s partly down to everyone putting all their eggs in the basket of out-of-hospital care. But these people still need hospital-based treatment for a whole range of conditions.”

There was also the NHS funding challenge, she said. While the emphasis had been on productivity, efficiency and service re-design, there had been no funding to cover the transition period, coupled with an automatic assumption that social care would be available. “But there isn’t the funding in social care, and we’re also in a real time of crisis in the NHS in terms of workforce. We’re haemmorhaging staff and that’s not a supply issue – it’s the fact that nurses don’t want to work in the NHS. We’re going to have to think quite differently if we’re going to meet this funding challenge.” Part of this was that “we don’t know how to use what we’ve got”, she said. “We need to allow people to focus on what they’re good at and where they add value.”  

Another key challenge was around structural governance, she pointed out. “Everything is supposed to work seamlessly for the benefit of the patient, but the Health and Social Care Act 2012 set into legislation the requirement to be competitive, so there’s a fundamental tension there.” Other structural issues were that foundation trusts were funded by activity rather than outcomes, which meant “putting the largest number of people through in the shortest amount of time”, with unintended consequences such as frequent re-admissions. “We’re also a default place for health and social care – if you have a crisis you go to A&E. That’s all part of the unpredictable demand that we have a statutory duty to meet.”

The NHS also faced a ‘massive’ regulatory burden, she said. “There are whole industries collecting data for regulation, and sometimes collecting it twice without talking to each other. That takes up an awful lot of time. There’s also an assumption that the NHS could be a lot more productive, and that everything could be provided in a standardised way. But there are fundamental differences in the structural circumstances of different trusts.”

Potential solutions included outcomes-based commissioning, outreach services, standardised outcomes instead of standardised inputs and agile systems that could flex to meet changing needs. Smarter and fairer regulation was also vital, and the NHS needed to become much better at contracting with the private and third sectors.

“So are the private and third sector the solution? They could be.” There was a great deal of expertise that the NHS could draw on, she said, in terms of innovation, economies of scale, investment in technology, expertise in non-clinical services and flexible supply, with the latter particularly important. “In the NHS we’re constantly running at 98 or 99% capacity so it could be that the private and third sectors could help us with those surges in demand.”

Public perception of the NHS meant that another advantage of working with these sectors was “if you get it right, you’re outside of that political minefield”. However, the NHS had traditionally been ‘quite poor’ at working with them, including areas like contract management. “There’s an issue with writing and managing the contracts, as well as with risk sharing. We can be very naïve about working with other parties. Yet working with other parties really is the only way we’re going to be able to manage the demand.”