The Development and Implementation of NHS Treatment ... · Development and implementation of NHS treatment centres Queen's Printer and Controller of HMSO 2007 Page 2 Contents Acknowledgements

The Development and Implementation of NHS Treatment Centres as an Organisational Innovation

Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO)

December, 2006

prepared by

Paul Bate, Glenn Robert Royal Free and University College Medical School, University College

London

John Gabbay Wessex Institute for Health R&D, University of Southampton

Steve Gallivan, Mark Jit, Martin Utley

Clinical Operational Research Unit, University College London

Andrée le May, Catherine Pope School of Nursing and Midwifery, University of Southampton

Mary Ann Elston

Royal Holloway College, University of London

Address for correspondence

Paul Bate

CHIME, University College London, London, N19 3UA

E-mail: [email protected]

Development and implementation of NHS treatment centres

Queen's Printer and Controller of HMSO 2007 Page 2

Contents

Acknowledgements 6

Executive Summary 7

The Report 12

Section 1 Studying diagnosis and treatment centres as an

organisational innovation 12

1.1 Introduction 12

1.1.1 Characteristics of a treatment centre 13

1.2 Aims of the study 14

1.3 The study design 15

1.3.1 The qualitative study 15

1.3.2 The quantitative (modelling) study 19

1.3.3 The literature review 19

1.3.4 Reporting anonymously 20

1.3.5 Outline of the report 21

Section 2 Roots and origins – where the innovation

came from 22

2.1 The pre-history and archetype of treatment centres 22

2.1.1 The Central Middlesex Hospital Ambulatory Care and Diagnostic Centre 22

2.1.2 The US ambulatory care model 25

2.2 Treatment centres and the NHS Plan 28

2.2.1 Reducing waiting times 30

2.3 The development of the treatment centre programme 2000- 2004 31

2.3.1 The role of the NHS Modernisation Agency 32

2.4 Summary 33

Section 3 Initial conditions for innovation? The local internal and

external milieus 34

3.1 The internal milieus 34

3.2 The external milieus 42

3.3 The importance of milieu 49

3.4 Opportunists, pragmatists, idealists and sceptics 49

Section 4 Taking up the challenge? The local motives for opening a

treatment centre 54

4.1 Improving quality 55

4.1.1 Patient care 55

4.1.2 Reforming professional practices 58

4.1.3 Promoting training and research 60

4.1.4 Optimising local premises 61



4.1.5 Improving staffing levels 63

4.2 Improving quantity 65

4.2.1 Meeting performance targets 65

4.2.2 Improving provision of services across the locality 66

4.3 Improving kudos 69

4.3.1 Improving the profile of the organisation 69

4.3.2 Realising personal ambition or vision 71

4.4 Summary 72

Section 5 Environment and influence: the wider context surrounding

treatment centres 74

5.1 The policy context since 1997 74

5.1.1 Policy documents and key events 75

5.2 Independent sector treatment centres 76

5.2.1 First wave procurement: 2003 77

5.2.2 Second wave procurement: 2005 78

5.3 Patient Choice 81

5.4 Payment by Results 83

5.5 NHS Elect 83

5.5.1 Origins and early history 84

5.5.2 Re-launch and expansion 85

5.6 Summary 86

Section 6 Achieving the goals? How the treatment centres

evolved 88

6.1 Planning 88

6.1.1 Incorrect planning assumptions 88

6.1.2 Pressurised planning 94

6.2 The shifting ground 95

6.2.1 The rise of the independent sector treatment centres 95

6.2.2 Patient Choice 97

6.2.3 Payment by Results 98

6.3 Relationships 98

6.3.1 External partners 98

6.3.2 Antagonistic relations 99

6.4 Competition and market forces 100

6.4.1 The lack of a level playing field 100

6.4.2 PCTs and SHAs 102

6.2.3 Marketing to potential users 105

6.5 Internal relationships 107

6.5.1 Recruiting key clinicians 107

6.5.2 Retaining managers 109

6.5.3 Other relationships and systems 111

6.5.4 The parent trust 113

6.6 Achieving targets 119

6.7 The study sites at the completion of fieldwork 121



Section 7 Improving practice? Evidence of innovation and new ways

of working 123

7.1 Changing practice 123

7.2 Changing the patients’ experience of care? 125

7.2.1 Physical surroundings 125

7.2.2 Innvoations in patient pathways 127

7.2.3 Innovations in staffing 135

7.2.4 Different ‘can do’ mentality 138

7.3 Summary: the struggle for a glass half full 140

Section 8 Quantitative studies related to treatment centre operation

143

8.1 Background – the key role of variability in determining capacity requirements 144

8.2 Example: the use of modelling in treatment centre planning 148

8.2.1 Planned theatre activity 148

8.2.2 Length of stay distribution 149

8.2.3 Results 150

8.3 Extension of modelling to better reflect the context of treatment centre of treatment centre operation 152

8.4 Possible extension of modelling to the case of multiple hospital environments 157

8.5 Modelling outpatient requirements 159

8.6 Summary 161

Section 9 Treatment centres and the efficient use

of capacity 162

9.1 One argument for introducing a treatment centre: managing variability 162

9.2 One argument for not introducing a treatment centre 164

9.3 Comparing capacity requirements with and without a treatment centre 166

9.3.1 The importance of taking a ‘whole system’ view 167

9.4 Modelling the intelligent selection of patients for referral to a treatment centre 167

9.4.1 The interplay between economies of scale and patient selection 169

9.5 Other factors that may influence the relative efficiency of different service configurations 170

9.6 Data collection 171

9.7 Results 176

9.8 Discussion 178

9.8.1 Aside: what if the treatment centre admitted longer stay patients? 178

9.8.2 Caveats 179

9.9 Summary 180

Section 10 Conclusions and discussion of the implications for policy,

concepts, practice and research 182

10.1 Conclusions 182

10.2 The ‘innovation journey’ 185



10.3 Policy implications of the research 187

10.3.1 The concept of innovation within the ‘new’ Government framework 187

10.3.2 Likely implications for service innovation and improvements 192

10.3.3 Research and policymaking in the NHS: modelling and the conflict of policies 201

10.4 Conceptual implications of the research 203

10.4.1 Planning and complexity 204

10.4.2 Sense-making and decision making 207

10.4.3 Conceptualising key success factors in health care innovation processes 211

10.5 Practice implications of the research 216

10.5.1 For policymakers 216

10.5.2 For change leaders and management practitioners 217

10.6 Implications for research 224

References 226

Appendices 236

Appendix 1 Information sheet for participants 236

Appendix 2 Interview sampling grids 239

Appendix 3 Literature review search methods 242

Appendix 4 Interview topic guides 256

Appendix 5 Results of CHIME survey of treatment centres 259

Appendix 6 An example of a patient pathway 268

Appendix 7 Department of Health’s health reform

framework 269

Appendix 8 Applying the Greenhalgh et al model to

NHS treatment centres in general 270



Acknowledgements

Contributors to the report

Paul Bate jointly had the idea for the study, participated in designing the

qualitative research, carried out fieldwork at one site, participated in the

analysis of the qualitative findings and participated in writing the report,

taking the joint lead in drafting the final section.

John Gabbay participated in designing the qualitative research, carried out

fieldwork at one site, participated in the analysis of the qualitative findings

and took the lead in writing the final report.

Steve Gallivan led the quantitative research team, the development of

mathematical models to assist TC planning discussed in Section 8 and the

writing of Section 8 and contributed to Section10. He also contributed to the

modelling work discussed in Section 9.

Mark Jit conducted the modelling work discussed in Section 9, contributed to

the design of this aspect of the study and also contributed to the modelling

work discussed in Section 8.

Andrée le May participated in designing the qualitative research, carried out

fieldwork at one site, participated in the analysis of the qualitative findings

and participated in writing the report.

Catherine Pope helped develop the qualitative research design, carried out

fieldwork at two sites, participated in the analysis of the qualitative findings,

participated in writing the report.

Glenn Robert jointly had the idea for the study, participated in designing the

qualitative research, led the sampling, carried out fieldwork at three sites,

participated in the analysis of the qualitative findings, and in writing the

report; he took the lead in drafting Section 5 and the joint lead on the final

section.

Martin Utley devised the theoretical evaluation of TCs with respect to the

efficient use of capacity discussed in Section 9 and led the writing of Section

9 and contributed to Section10. He also contributed to the modelling work

discussed in Section 8.

Mary-Ann Elston carried out the literature review that formed the basis of

Section 2.



Executive summary

About this report

This three-year study examined the ‘journeys’ of eight National Health

Service (NHS) treatment centres (TCs) as organisational innovations. In order

to do this we:

1 conducted a technical evaluation (incorporating mathematical modelling)

both of the concept and actual impact of TCs as an innovative way of

delivering health care within the NHS

2 studied – using qualitative methods – the organisational and social

factors associated with the development of TCs in order to demonstrate

how these impact upon the implementation process and its outcome.

This report is based on data we collected through over 200 interviews with

key stakeholders within the TCs, their host trusts and their local health

economies; observations of meetings, of TC practices and general

interactions; and documentary analysis of business plans, trust governance

documents and marketing materials. Our synthesis of these data, together

with the mathematical modelling exercises, was used to develop a series of

key findings of relevance to policymakers, service planners, practitioners and

those interested more generally in the diffusion of innovation and change

management.

The cultures of our eight sample sites that chose to open TCs were all very

different. We found a range of management styles, aspirations, interactions

and drivers within the TCs. However, the one factor which united them was

the sense that this particular organisational innovation was timely and

necessary; alongside this we found a ‘can do’ mentality and the presence of

some core ‘champions’ who were keen to implement this new organisational

form. The milieu of the nascent TCs – their local health economy including the

host trust, the primary care trusts (PCTs), the strategic health authority

(SHA), neighbouring trusts, and their own internal staff – also showed a wide

range of relationships that appeared to run along a continuum from hostility

and conflict with most of the major stakeholders, through to much more

harmonious and constructive partnerships with the major players, with

examples of most points somewhere in between these extremes.

The local organisations that took up the challenge of establishing a TC did so

for a wide variety of reasons. In addition to the generally favourable policy

environment, local motivations to open a TC were often rooted in local history

and context (for example pressure to find new capacity to treat patients on

their own or other hospitals’ waiting lists, a stalled plan to relocate surgical

services or open a day-surgery unit, the need to find a use for an underused

hospital building, the chance to engineer changes in local professional

influence, and so on), which conspired to drive each local initiative forward.

While to some extent these motivating factors were unique to each of our

sites, some common features emerged.



Firstly, the people. The decision to apply for TC funding inevitably resulted

from the resolution of a number of often conflicting views (which we have

referred to as contests of meaning). These were clearly influenced by key

players who were themselves subject to pressures from the internal and

external milieus of their organisations. For example there may have been –

and usually were – idealists who saw the TC as a specific opportunity to

transform patient care. But there were nearly always sceptics who saw it as

yet another fad, opportunists who wanted to secure funding to develop a new

service that was – in their view – much needed, and pragmatists who wanted

to do whatever seemed most likely to improve services with minimum fuss.

Even where there was consensus among those with the power to make the

final decision, there were always discrepancies about their underlying

motivations, rationales and intended outcomes, resulting in evolving and

constantly negotiated clusters of decisions that gradually emerged as

something approaching (at least) some of their initial visions of a TC.

Secondly, a unifying thread in the various reasons why these sites developed

TCs is the sense that they wanted to bring about change – to ‘improve

quality’, to ‘improve quantity’ or to ‘improve kudos’. In improving quality sites

determined to transform the elective care environment (for example new

buildings, infrastructure and clinical and administrative practices). This

included fundamental reform of traditional clinical practices and

transformations in skill-mix. In improving quantity the case studies were

hoping to increase capacity, throughput and activity, and in this they were

tightly coupled to a performance agenda set down by the Department of

Health which was concerned with reducing waiting times and increasing

activity. In improving kudos for the organisation the sites were hoping their

TC would make their organisation more competitive (or at the very least

prevent them falling behind and becoming uncompetitive). Some sites also

used ties with external stakeholders (SHAs, the NHS Modernisation Agency or

the Department of Health) as a way for the TC to improve the profile of the

wider trust (or of key personnel within it).

Thirdly, all our sites experienced a variety of problems related to imprecise

planning, financial setbacks and (usually) overcapacity, and all experienced

some degree of evanescence of some of the original motivators for change,

such as the principle of nurse-led care or other shifts in professional roles. For

a variety of reasons, almost none of the TCs was able to plan and predict with

any consistency or precision even such basic parameters as the numbers and

types of patients they would treat. The way that the TC fared once it had

opened depended partly on the changing state of the local health economy

which was shifting constantly in the maelstrom of central initiatives and the

very varied local responses to them. These included a programme of

independent (private) sector TCs as part of a wider governmental push

towards involvement of the private sector in the delivery of care, presaged in

The NHS Plan (Department of Health, 2000a); the introduction of Payment by

Results (Department of Health, 2002a), a new system for reimbursement;

and the simultaneous introduction of the Patient Choice initiative

(Department of Health, 2003a) and the Choose and Book programme

(Department of Health, 2004a). Many of these had not only indirect but direct

impacts on the ways the new TCs functioned (for example the financial

incentives – or disincentives – for local trusts to send them patients). The

outcome for each site depended on how the managers of the TCs were able to



respond to this rapidly changing environment, which in turn depended on the

relationships they had with key stakeholders in their local health economies.

In this respect the TC managers and those of their host trust were, by their

responses, enacting the environment with which they subsequently had to

cope (for example, by the kinds of competitive or collaborative relationships

they established with key local stakeholders).

Despite the turmoil, however, there was often perceived to be a positive

impact on patient flows – such as increased throughput and a decrease in

waiting lists – and significant innovations in the processes of care. These

included preoperative assessment done by nurses via a questionnaire, a

nurse-led clinical pathway about which patients were fully informed before

arriving at hospital, well-honed individual care pathways with key milestones

(based albeit sometimes controversially on models from the United States

[US]), case managers in charge of discharge planning, PCTs providing

planned intermediate care, and considerable redesign of the workforce and

the physical environment in order to accomplish these new ways of working.

But often the eventual changes were relatively superficial (‘first order’ rather

than ‘second order’ transformation). By the end of the three-year study, three

of the eight sample sites remained (partially) identified with the NHS-run

programme, one had closed, one had been bought out by a private health

care provider and three were at some stage of becoming linked with the

independent sector. Only one of these appeared to have weathered the storm

by emerging as a stand-alone NHS TC which closely mimicked the original

exemplar of the policy model of what an NHS TC should be.

Finally, while we have shown that it is possible mathematically to model ways

to optimise patient flows and bed capacity, the planning capacity of NHS

management in the frenetic environment in which TCs were being developed

meant that such considerations appeared much less relevant than perhaps

they ought to have been. It was possible through our mathematical modelling

to show, for example, that there were some circumstances under which the

introduction of a TC might be predicted to offer little if any benefit to the local

health economy, and indeed that serious problems of overcapacity might

result (as in the event it did do, in just the kinds of sites that the model

predicted). Yet despite the apparent strength of such logical argument, the

local political and clinical context, motivations and environments would have

made it impossible for such a finding to carry any weight in the complex

evolution of plans, negotiations and implementation that occurred in all eight

case study sites.

Practical implications of the research

For policymakers

1 Top-down, target-led central innovations will inevitably be recrafted at

the local level to suit local needs and build on existing initiatives; they

need therefore to retain appropriate flexibility (headroom) if they are to

be crafted while still successfully fulfilling their core objectives.



2 Policymakers should try to facilitate local innovation using ‘design

principles’ that acknowledge the likelihood that rational planning of

innovations will be limited in both its feasibility and its applicability in the

‘volatile environment’ of NHS management.

3 There should be more rigorous evaluation of innovative policies while

they are on the drawing board, and where this reveals strong evidence –

for example from modelling techniques – that problems will arise from

the widespread implementation of an innovation, caution should be

exercised.

4 Assessments of the likely impact of new policies on those that are

already working their way through the system should be undertaken

before a new policy is introduced nationally.

5 Even where an organisational innovation has all the attributes of likely

success (for example it is widely acknowledged to have high relative

advantage; it is apparently compatible with the values, norms and

perceived needs of those who are expected to adopt it; and it has the

potential to be adapted to a range of local requirements) there is no

guarantee that it will work. It is also necessary to explore very carefully

the potential interaction between the innovation, its intended adopters

and its context when assessing the likelihood of successful

implementation.

6 Specific training may be required among managers at all levels of the

NHS, as successful implementation of organisation-wide innovations

require a high level of both strategic and front-line change management

skills, which are often in short supply.

7 Where an organisation’s existing knowledge and skills base are

insufficient, then the use of external change agents to support

implementation may be required but is unlikely to succeed unless there

is a common language and values system, and shared meanings between

the policymakers, the facilitators and the front-line innovators.

For change leaders and management practitioners

Service innovation is a social and organisational process, which means that

the management of innovation is predominantly an issue of managing the

social and organisational factors associated with that process. We have

identified 74 such factors from our research on TCs. We have detailed these

at the end of this report in the form of ‘design principles’ for managing

innovation in service delivery and organisation. These 74 principles are

categorised in Section 10 under seven headings:

1 dealing with complexity, non-linearity and unpredictability

2 creating ‘enabling’ structures and systems

3 navigating the politics of innovation and securing stakeholder

engagement

4 building the innovation network

5 creating a learning process

6 changing behaviour and culture



7 leadership.

Implications for future research

1 Research is needed on the appropriate balance between centrally-

generated innovations and those that are generated locally and

disseminated laterally. The intended shift in the policy environment from

the former to the latter will provide an interesting natural experiment.

2 Work is needed to help develop and evaluate the concept and use of

‘design principles’ in facilitating successful innovation. For example,

within the new NHS policy context it might be possible to work with SHAs

(perhaps using an action research or formative evaluation design) to

explore the place of design principles for organisational innovation at the

local level.

3 The nature and place of ‘positive organisational scholarship’ – a

management paradigm which focuses on positive aspects and identifies

opportunities (Camerson et al, 2003) – should be explored as a means of

fostering a more receptive environment for organisational innovation.

4 We need to understand more about how middle managers such as the

managers of the TCs and front-line NHS staff in general – given their

central role in innovation – make sense of and therefore contribute to

change outcomes in different change contexts. Relatedly, more work is

needed to understand how the inevitable contests of meaning in multi-

level and multidisciplinary organisations can be more successfully

reconciled.

5 What are the sources of evidence that decision-makers draw upon when

making the decision to innovate, and how are these played out in the

negotiations and debates that precede the decision and subsequently

shape its journey? In particular, how do political and power relations and

organisational roles impact on this process?

6 A study is needed to explore the barriers and opportunities for change

based on the findings of theoretical planning exercises and operational

research studies. In particular what might better facilitate the influence

of such evidence on service delivery and organisation within the NHS?

Relatedly, a study is needed that explores the ways in which modellers

and operational researchers might dispel the ‘Cassandra complex’ that

currently affects much of their work.

7 A highly relevant methodological question is how researchers can best

handle the problem of studying an organisational entity that is subject to

a range of – sometimes incompatible and/ or shifting -meanings held by

key players.



The Report

Section 1 Studying diagnosis and treatment centres as an organisational innovation

1.1 Introduction

Diagnosis and treatment centres were launched as a new NHS initiative with

the publication of the Government White Paper The NHS Plan (Department of

Health, 2000a). As a model of service delivery, diagnosis and treatment

centres sought to streamline patient care, thereby reducing not only the

likelihood of inappropriate delays either in access to care or between care

events but also the long waiting times for routine, short-stay elective surgery

which were plaguing the NHS at that time. The explicit core principles behind

diagnosis and treatment centres were the separation of elective from

emergency and unplanned treatment, and, in line with the ‘modernisation’

agenda, the re-organisation of treatment delivery (and, to a varying extent,

diagnostic services) into more patient-focused processes. Widely proclaimed

as being in the vanguard of ‘modernisation’, diagnosis and treatment centres

were intended to go beyond redesigning treatment spaces and patient flows

to embrace a whole new philosophy of care, one intended to fundamentally

rethink the way health services are provided and maintain the patient-centred

nature of modernisation. This ‘new way of working’ necessitated deep-seated

changes both in how people worked and the culture in which they worked.

The Government’s original aim was that by 2004 at least eight such diagnosis

and treatment centres would be fully operational, treating approximately

200,000 patients a year. It was clear very early in the programme that the

scale of the innovation would be much larger than that, affecting thousands

of staff and hundreds of thousands of patients. A first wave of four diagnosis

and treatment centres was announced in 2001 and a second wave of a further

four centres in February 2002. In the same year came the announcement

(Department of Health, 2002b) that 36 additional diagnosis and treatment

centres would be operational by 2004, 10 of which were to be ‘trailblazing’

new-build centres. The services offered in diagnosis and treatment centres

varied but included ear nose and throat, general surgery, gynaecology,

ophthalmology, cardiology, urology, pain clinics, chemotherapy, sickle-cell

clinics and maxillofacial surgery.

Since those early announcements, the number of service delivery

organisations that come under the banner of this initiative – subsequently

relabelled as ‘treatment centres’ (TCs) – has risen to 46 in the NHS and 17 in

the private sector. The Government expected there to be 80 by the end of

2005 (Department of Health, 2005a). Just as the number of TCs expanded so

too has the list of services offered in these centres, almost all specialties that

can offer routine, short-stay care are now available.



Whatever the specialty, the defining characteristics of TCs were to deliver

high volumes of high quality care using modern, efficient methods, with an

emphasis on patient choice and convenience. The key was separating elective

from emergency care so that TCs could concentrate on delivering booked

services according to planned protocols. To achieve these aims, there was a

guiding expectation that novel patient pathways would be planned that did

not necessarily treat conventional departmental or professional boundaries as

sacrosanct. The new model of care was expected to be innovative in being

exceptionally patient-centred and, where possible, offering a ‘one-stop shop’

where the provision of diagnostic and treatment services improved both the

efficiency of the service and the experience of the patient.

1.1.1 Characteristics of a treatment centre

These defining characteristics of TCs were frequently reiterated in Department

of Health and NHS material. Such sources also frequently repeated the point

that there was no single model for a TC, whether run by the NHS or the

independent sector. Rather than a single ‘right model’ for all circumstances,

TCs could be anywhere on a continuum from relatively simple primary-care

based developments through to full blown elective ‘factories’, with traditional

day case units in between. For example:

Treatment centres will vary in the types of services they offer depending on the

local demand for health services.

(Department of Health, 2004b)

For the NHS, DTCs [diagnosis and treatment centres] offer an opportunity to adopt best

practice and increase short term capacity through new ways of working. There is not

one prescribed model for a DTC; for example it could be on NHS property or in a

shopping centre. There are no set ideas on structure as long as the DTC is fit for

purpose. Trusts may even want to consider leasing a facility and learning from how this

works before building a tailor-made DTC..

(Ken Anderson, Department of Health, Architects for Health Conference, 2003)

The Modernisation Agency, which had been set up to oversee and guide the

modernising of the NHS had the task of co-ordinating a collaborative

programme to support these developments in TCs. By the time our study

began in 2003, the Modernisation Agency gave the following as a description

of the core characteristics a TC (NHS Modernisation Agency, 2003a):

The goal of a treatment centre is to deliver high quality, cost effective scheduled

diagnostic and/or treatment services that optimise service efficiency and

clinical outcomes and maximise patient satisfaction. The defining

characteristics of a treatment centre are that:

1 It embodies throughout its life the very best and most forward-thinking

practice in the design and delivery of the services it provides.

2 It delivers a high volume of activity in a pre-defined range of routine

treatments and/or diagnostics.

3 It delivers scheduled care that is not affected by demand for, or provision of,

unscheduled care either on the same site or elsewhere.

4 Its services are streamlined and modern, using defined patient pathways.

5 Its services are planned and booked, with an emphasis on patient choice and

convenience together with organisational ability to deliver.



6 It has a clear and trusted identity that is valued by its patients and by its

other stakeholders.

7 It provides a high quality, positive patient experience.

8 It creates a positive environment that enhances the working lives of the

people who work in it.

9 It adds significantly to the capacity of the NHS to treat its patients

successfully.

We selected TCs as the focus for our study because they exemplified the

increasingly complex and dynamic nature of service delivery innovations,

involving multiple professional and occupational groups as well as major

technological and organisational change.

Being newly arrived on the scene, they also offered a unique opportunity for

us to watch the unfolding of an innovation over time. On this point,

Greenhalgh et al argue that ‘the main gap in the research literature on

complex service innovations in health care organisations is an understanding

of how they arise, especially since this process is largely decentralised,

informal and hidden from official scrutiny. An additional key question is how

such innovations are reinvented as they diffuse within and between

organisations’ (2005, p.17). Studies of major innovations in health care

organisations have seldom been able to evaluate the growth and

development of such innovations over time. Our study sought to address this

research gap by providing a longitudinal analysis of the development of TCs,

from their initial conception through the early implementation, and following

their evolution. The SDO Programme commissioning brief for this study noted

a particular interest in evaluations of innovations which related to NHS

priorities and the implementation of the NHS Plan. This study of TCs provides

a much needed understanding of how one such central component of these

NHS priorities and the NHS Plan is being implemented.

1.2 Aims of the study

Within this context, the overall aim of our study was to describe and evaluate

the way in which the innovation of the TC was implemented in a selected

sample of NHS trusts. Our study focuses on TCs run by the NHS. Private

sector TCs are mentioned in the context of how they influenced the

development of NHS-run TCs; however they were deliberately not included in

our study sample.

The study had two separate strands:

1 a technical evaluation (incorporating mathematical modelling) both of

the concept and actual impact of TCs as an innovative way of delivering

health care within the NHS

2 a qualitative study of the organisational and social factors associated

with the development of TCs in order to explore how these impact upon

the implementation process and its outcome.

We had originally also proposed both to evaluate TCs and to explore how

formative feedback and the sharing of different types and sources of

knowledge (from the two strands of our study) influenced the development of

TCs. In the event, as we shall describe, TCs developed very much as local

solutions to organisational problems in a rapidly changing and sometimes



chaotic environment. Those planning and running TCs showed little sense of

being a community of organisations implementing a similar innovation. To

have attempted, therefore, to focus on the objectives of evaluation and

feedback of the TC programme would have been neither helpful to those

implementing TCs nor realisable within the scope of this study. Moreover,

such a focus would have drawn attention away from what became the most

interesting aspects of the study, namely the ways in which the innovation

evolved variably in response to the interplay between powerful national and

local forces.

1.3 The study design

1.3.1 The qualitative study

We used a multi-method case study design (Eisenhardt, 1989; Yin, 1994 and

2003). We selected eight case study sites, using the preliminary information

that we had gathered in preparation for the proposal. The selection of sites

was also informed by meetings with the director and members of the national

Modernisation Agency team responsible for the TC programme. The sampling

was intended to ensure that the case study sites provided a broad

representation of the range of TCs either existing or in development as at

March 2003 when the research began. In addition, two of the authors (Bate

and Robert) were involved in an interview-based survey of all the early TCs.

Further details of this work can be found in Appendix 5.

The selection characteristics that we considered were:

• geographical (for example urban/rural)

• type of host trust

• organisational (for example integral or separate from host trust; star

rating of host trust; likelihood of gaining foundation hospital status)

• intended casemix (for example single or multiple specialty, routine or

more complex cases)

• the stage of development (from those that were already open, through to

those in the early planning stage)

• scale (as measured in terms of the number of planned full consultant

episodes or ‘FCEs’)

• new/purpose built or not

• degree of private sector involvement

• commissioning model (for example reliant on multiple or single

commissioners).

Ethical approval for the study was sought from a Multi-Centre Research Ethics

Committee (MREC) in January 2003, and full approval was granted on 14

April 2003. Management approval for the study from the relevant NHS trust

chief executive or TC director in each of the sites was then obtained.

Following changes to NHS ethical procedures the study was designated as a

‘no local researcher’ study in May 2005 by the chair of the MREC which had

originally approved the study and – as such – local ‘site specific approval’ was

not required.



All but one of our original choices agreed to be case study sites (see Table 1).

The sites were given an information sheet about the study (Appendix 1), and,

when they had accepted, a local ‘site representative’ was appointed from

among the senior staff associated with the TC. With the help of this person,

key initial informants in each site were selected for interview, based on their

roles and involvement with the TC (see Appendix 2 for the sampling grid).

The sites selected ranged from relatively small initiatives (the single ward

that formed stage I of Site B) to much larger enterprises including centres

that operated essentially as mini-hospitals (Sites A and C) and treated twice

as many patients as our smallest site (Site D). Some were complete new

builds (stage II of Site B), some were new extensions to existing facilities

(Sites C, D, H, and G) and some refurbishments of facilities within the ‘host’

organisation (Sites E and F). The earliest date of opening was in 2000 with

the latest (stage II of that same site) due to open in 2007/08. The sites

varied in terms of activity or scale as measured by the approximate number

of patients intended to be treated each year when the TC was fully

operational (measured in ‘finished consultant episodes’). Sites A and C were

expected to have the highest activity, double that of the smaller sites like B

and D. All the sites eventually selected were based in acute trusts and

perhaps because of this most were in urban settings although the

geographical locations covered included city centres, and towns near more

rural areas and the coast. One site had major private sector involvement in

the building work but was an NHS facility. The organisational status of the

sites included trusts with ratings of between zero and three stars; one was

granted foundation hospital status during the course of the study and others

were in various stages of planning to do so.

This fieldwork was undertaken over two and a half years and principally

entailed organisationally-focused interviews with key informants who were

either involved in the design and delivery of the TC or among those

commissioning its services, direct observation of the TC’s workings (for

example the site development, TC meetings and educational events), and

documentary analysis (for example reviewing business plans, board minutes,

annual reports). In addition, to contextualise our case study work we followed

policy changes and undertook a comprehensive literature review of published

and grey literature (see Appendix 3 for details of the search strategies and

Section 2 for the review).

Our intention was to use these data to compile organisational case studies in

order to understand the interactive and political processes which shaped the

development and functioning of the TCs including the roles of key

actors/teams in implementing a new system of care. We hoped also to

understand how the local and wider health economies both perceived and

impacted upon each of the TCs.



Table 1 The sites

Site Open Scale Physical relation to host hospital

A 2002 7000 Separate site, stand-alone

B 2003

2007

4115 (I) Continuation of pilot in ‘host’, first opened in 2000

(II) New build

C 2005 6588 New build extension to a new hospital

D 2004 3150 New build extension to ‘host’

E 2003 4500 Refurbishment of existing building on ‘host’ site

F 2002 3500 Major refurbishment of private patients wing in ‘host’

G 2003 4600 New build extension to ‘host’

H 2004 3400 New build extension to existing hospital

We carried out the interviews in two phases, the first focusing on the internal

organisation of the TC and its host trust, the second on members of the local

health economy such as representatives of relevant PCTs, SHAs and

neighbouring trusts. We used a snowball sampling technique in both phases,

starting in phase one with the initial key players (for example the chief

executive of the host trust and the TC manager/core team) as identified by

our site representatives. The initial interviewees were asked to recommend

other significant informants and so on until, again with the help of the site

representative, we considered the sample to be complete across all the

relevant parts of the system. We also consulted key personnel at the

Modernisation Agency and several of our sites were members of NHS Elect, a

confederation of NHS elective care providers, which led us to interview senior

staff from this organisation as part of the second phase of our fieldwork (see

Section 5).

Interviews were semi-structured and were nearly all audio-recorded and

transcribed. Most of them were face-to-face, sometimes with more than one

interviewee at the same time. Where necessary in a minority of instances, the

interviews were done by telephone. We used a set of interview prompts to

guide our approach throughout to ensure consistency between members of

the research team (see Appendix 4) and the ‘defining characteristics’ of a TC

as identified by the Modernisation Agency (see Section 1,1.1).

We carried out 201 interviews in all, across a range of categories of

interviewees, who may have been interviewed between one and five times

(Table 2).



Table 2 The interviewees

Category of interviewee Number interviewed in each category

Host trust

Chief executive officer

Senior trust managers

TC project co-ordinators

TC non-clinical managers

TC clinical leads

TC clinical managers

Other clinical specialists

Other support specialists

5

30

9

24

32

17

7

6

External stakeholders

PCT chief executive officer

PCT senior managers

SHA senior managers

Other acute trust managers

Others miscellaneous managers

TC/Modernisation Agency links

5

9

13

3

6

3

At most sites we also undertook opportunistic non-participant observation of:

1 decision-making interactions, for example:

- formal and informal networking within the TCs, such as project

management meetings, clinical pathways design groups, staff away

days and training events run by external consultants

- between TCs and their parent organisation, for example trust board

meetings which focused on TC-related topics such as capacity

planning, case mix and complaints

- between the TCs and service users, such as patient involvement and

open days

- between TC members at the Modernisation Agency’s learning events

2 the processes of care and the physical environment of the TCs, for

example:

- guided tours of facilities or patient pathways

- visits to building sites to view construction

- staff open days.

We carried out an analysis of a number of documents, including business

plans; minutes from internal TC team meetings and trust board meetings;

protocols and guidelines; press cuttings; key sources of information such as

guidance for clinicians, and information sheets and booklets provided to

patients and their carers. These analyses complemented the data gathered

from the observation and interviews described above.

Because of the emerging emphasis of the study towards organisational and

policy questions, and also because the NHS rules on ethical approval changed

midway through the study, we did not interview patients. This was discussed



and agreed with the funders of the research at a progress report meeting in

2005.

Qualitative analysis

The qualitative research team iteratively shared and thematically analysed

the data, building theory from the case studies along the lines described by

Eisenhardt (1989):

• analysing within-case data (which involved for each site several detailed

case study write-ups and presentations to the team)

• searching for cross-case patterns (for example selecting categories and

then looking for between-case similarities and differences)

• shaping propositions (an iterative process in which we worked as a team

to sharpen our constructs and definitions, building and re-examining the

evidence to assess the constructs in each case; and where possible

verifying and testing our emerging ideas – often during the interviews

themselves – with those involved)

• enfolding literature (comparison of emergent concepts and hypotheses

with the extant literature)

• reaching closure (deciding when ‘theoretical saturation’ is reached).

1.3.2 The quantitative (modelling) study

We employed mathematical modelling techniques based on probability theory

to evaluate a large number of hypothetical scenarios and thereby identify

circumstances where the introduction of a TC could improve the efficient use

of capacity within a local health economy and circumstances where such an

improvement is unlikely (see Sections 8 and 9 for full details of the methods

employed).

It is important to note that there is a symbiotic relationship between the

quantitative and qualitative research, which may not be fully apparent from

the structure of the report. This is because the structure reflects the different

research methodologies employed, which in turn generated insights

concerning different dimensions of the introduction of TCs. This point is

considered further in Section 10.

1.3.3 The literature review

Professor Mary Ann Elston (Emeritus Professor, University of London) carried

out a review of the background literature on TCs as an integral part of our

research. Her brief was:

1 to track the UK policy literature on TCs

2 to analyse the US literature and identify what lessons have apparently

been taken from the US for adoption in the UK

3 to identify what features delineate critical success in implementing

concept of TCs in the NHS

4 to identify gaps and themes in the existing literature/evidence base to

aid development of research questions in fieldwork and primary data

analysis.



Additional details of the search strategies used can be found in Appendix 3.

Besides specific searches, some analysis was undertaken of more general

background health services research and policy literature. For example, some

publications on wider aspects of NHS health care policy developments, and

health services research related to organisational change and quality

improvement initiatives (among other things) were referred to in order to

contextualise the TC initiative.

The initial electronic data base searches listed in Appendix 3 generated 470

items. Duplicates, and items about interventions other than those that are

generally planned for TCs (for example pharmaceutical interventions), and

clinical or economic evaluations of procedures (for example comparisons

between day and inpatient surgery) were discarded, leaving 287 possible

items. A further 135 items were added manually as a result of further

searching and citation tracing, and ongoing updating of news coverage. None

of the retrieved items directly about TCs per se (rather than background

aspects or related developments) were research articles in peer-reviewed

journals.

Given this, and the sheer volume and mixed provenance of broadly relevant

material, the decision was taken to concentrate on the greyer, policy-

orientated literature in order to produce a narrative about the development of

TCs. Further selection from within these 450 items (approximately) was

based on perceived relevance to the topic. In all, around 300 items were

directly scrutinised for the review. It should be noted that much of the

included material emanates from government departments and agencies, and

needs to be interpreted accordingly. Journalistic sources will accentuate any

controversial or problematic aspects of TC development.

1.3.4 Reporting anonymously

Confidentiality and anonymity are vital in a report such as this, and were a

condition of site participation. We have therefore deliberately kept the details

of most of the sites fairly vague (such matters as numbers, sizes, budgets,

architecture, job titles and so on) and reported sites in such a way as to try

and disguise them. But inevitably – unless we render all the data so indistinct

as to become useless – the sites will be recognisable to those who are ‘in the

know’ already. Our feeling from the discussions that we had is that those who

are able to recognise the sites will probably not learn very much about what

happened there that they are not already well aware of. On those few

occasions where the point may have personal repercussions, and the exact

source of the quote is not important to our argument, we have kept

quotations but have not attributed the source.

Because we use very general job titles to help maintain anonymity, we have

also used the convention that if there are two quotations in succession from

people with similar jobs in the same site, we refer to the second as, for

example, ‘senior manager II’. But this is merely to distinguish them from the

preceding interviewee, not to label them: in a subsequent citation they would

normally be simply ‘senior manager’. Also to help maintain anonymity all the

sample sites are labelled TCs regardless of their actual titles in the NHS.



1.3.5 Outline of the report

Section 2 is based on the review of the literature and outlines the origins of

the TC model, both in the UK and the US ambulatory care model, that

preceded the launch of the Government’s TC programme. We explore the

background to that programme, including the reasons behind the initiative

and the intentions that the government and the Department of Health had for

it when they launched it in the NHS Plan (Department of Health, 2000a). We

also briefly outline the subsequent rapid development of the programme and

the part played by the Modernisation Agency. Section 3 describes the internal

and external milieus of all eight sites, which formed the receptive context for

the innovation. We show how varied were the local cultures and concerns that

lay behind the decision to open a TC as part of the national programme, and

we describe the ‘ideal types’ of idealists, opportunists, pragmatists and

sceptics who were engaged in the debates about that decision. In Section 4

we thematically analyse the motivating factors that persuaded the senior

teams in all eight sites to establish a TC in their locality, grouped into the

main categories of:

1 the desire to improve quantity (for example patient throughput)

2 quality (for example patient pathways)

3 kudos (organisational and individual profile and status).

The main government and Department of Health policy initiatives that

subsequently impacted on the TCs, such as the increasing stress on

independent sector TCs, Patient Choice and Payment by Results are set out in

Section 5, which also outlines the development of an organisation of a small

confederation of TCs called ‘NHS Elect’. In Sections 6 and 7 we describe and

thematically analyse how the TCs evolved. Section 6 discusses the ways in

which initial plans rarely worked out as intended, and considers the roles

played by the pressurised nature of the initial planning, by the subsequent

impact of shifts in national policy, by the state of relationships with partner

organisations including the host trust, and by the internal developments and

staff changes. Section 7 describes the stated changes that occurred in the

care patients received, and discusses briefly how this was achieved and how it

was perceived. In Section 8 and 9 we turn to the quantitative study and the

use of mathematical modelling, firstly in the context of TC operation and

planning, particularly in relation to questions of capacity requirements, and

then in Section 9 in identifying circumstances where the introduction of a TC

might improve its local health economy– or not. We conclude in Section 10

with a summary of our main findings, followed by a discussion of the

implications of our research for future policy, practice, and research with

regard not just to TCs but organisational innovations and service

development more generally in the NHS.



Section 2 Roots and origins – where the innovation came from

This section reports the literature review that was undertaken for the study

(see also Section 1.3.5 and Appendix 3) and seeks to provide important

material relating to the origins and historical development of the TC as an

organisational innovation. An understanding of the history and genesis of this

innovation is crucial to understanding the national and local implementation

of the TC policy and the evolution of this particular organisational innovation.

2.1 The pre-history and archetype of TCs in the NHS

The concept of the TC had a history that began in the UK well before the NHS

Plan (Department of Health, 2000a). Indeed there were some prototype TCs

before this date, modelled on ambulatory surgical centres (ASCs) and other

forms of ‘focused factories’ which had existed in US health care since the

1970s. Neither the archetype nor its context was therefore wholly new to the

NHS. There had been an attempt, for example, to set up a ‘hernia factory’ in

the Midlands in the mid 1990s, and one of our sample TC sites had been

under consideration as a stand-alone elective surgery centre as early as

1997. Some five planned ambulatory care centres in England, two of which

subsequently became part of the TC programme, were referred to in a report

in the mid 1990s (NHS Estates, 1996; p.4) and/or in a later report

commissioned to help in the planning of a number of such centres in Scotland

(Mould and Bowers, 2001). But it was the Ambulatory Care and Diagnostic

Centre which opened at the Central Middlesex Hospital in North West London

in 1999 that was much the most cited as a prototype for the TC programme.

2.1.1 The Central Middlesex Hospital Ambulatory Care

and Diagnostic Centre

The Ambulatory Care and Diagnostic Centre was officially opened by Prime

Minister in December 1999, and heralded as a ‘flagship’ in the Labour

Government’s drive for NHS modernisation. In fact the centre had been under

active development since at least 1994, and was announced in press releases

in 1996 (NHS Estates, 1996), with construction contracts signed before May

1997. The centre was variously described as:

Essentially a hospital without beds for elective procedures.

(Foreword to NHS Estates, 2001)

…the revolution in care that you have pioneered here is to be applied all over

the country..

(Prime Minister Tony Blair, 2001; speaking at the Ambulatory Care and Diagnostic

Centre)

The ACAD [Ambulatory Care and Diagnostic Centre] experience could be

compared, for example, to the experience most people have when they visit a

small airport..



(NHS Estates, 2001)

The Ambulatory Care and Diagnostic Centre is a purpose-built unit on the site

of, but administratively distinct from, its host hospital. In its early days the

centre undertook pre-booked elective day case general surgery, breast

surgery, ear nose and throat procedures, orthopaedics, gynaecology, urology

and ophthalmology. Inpatient stays – usually of up to 23 hours, but bookable

for a stay of up to five days – were possible in ‘step-down’ beds within the

centre, but were only needed for around five per cent of patients. The

particular distinguishing features of the centre relative to conventional day

case units were the ‘strong emphasis on protocol-driven care’ and the

significant role played by the ‘scheduler’ in the organisation (Bowers et al,

2002; p.306). The scheduler’s role was to make appointments according to

protocols for specific procedures, liaising with patients and/or GPs directly to

reduce non-attendance. Schedulers were said to ‘supersede the roles of

medical secretaries and ward and clinic clerks’ working in teams and directly

responsible to the centre’s manager, not to individual consultants (Morgan

and Layton, 1999). These schedules were arrived at after a detailed exercise

of ‘process mapping’ begun in 1994, in which the team at Central Middlesex

Hospital had developed from simple first principles – ignoring traditional

organisational constraints – integrated care pathways that focused solely on

the needs of the patients undergoing 126 different kinds of elective procedure

(Morgan and Layton, personal communication 2002).

The result, Bowers et al (2002) suggest, of a ‘combination of predictable,

routine patients and a reliable supply of resources [was] to enable the

delivery of streamlined health care with few sources of delay’ (ibid; p.308).

The model of ‘ambulatory care’ adopted at the Ambulatory Care and

Diagnostic Centre was not just of a clear separation of elective and

emergency cases, but handling only those elective patients whose treatment

or diagnostic intervention requirements and suitability for day or short-stay

procedures had been previously determined. Outpatient consultation and

diagnostic services were organised by the main hospital, even when requiring

use of radiology facilities physically located within the centre. GPs were

reported as having only very limited direct access to centre (for minor

surgery).

The Ambulatory Care and Diagnostic Centre was constructed as a purpose-

built, two storey, free-standing unit at the edge of the Central Middlesex

Hospital site in North West London. The building itself has won high praise

from those involved with construction and facilities provision in health care.

‘It has been described as one of the most seminal (sic) health care buildings

of the last decade’ according to the website of the architectural firm

responsible for its design (Avanti Architects, 1999). The building’s innovative

design, the close identification of the NHS Estates unit with its development,

and the fact that the building itself was constructed within contract time (85

weeks) and within budget (around £11m for building costs out of a £19m

total budget) (NHS Estates, 2001), probably contributed to the Ambulatory

Care and Diagnostic Centre’s high profile in UK health care, quite independent

of its clinical or service delivery achievements. The building was designed,

according to the project’s consulting structural engineers, in accordance with

the radical vision of service delivery: separation of elective and emergency

care, allowing ‘walk in/walk out’ patient flow, flexible design to accommodate

future innovation in both equipment and procedures, with quality of space



valued, no need for traditional wards, and an emphasis on high speed

electronic information storage and transfer.

The skill-mix deployed in the centre and some aspects of the terms and

conditions of service for nurses were different from what was usually found in

acute health care in the NHS. This resulted from a systematic attempt, based

on the process mapping and care pathways work, to redesign professional

roles irrespective of traditional professional boundaries. By 2001, there were

48 full-time equivalent registered general nurses but only nine health care

assistants. Nurses rotated weekly through the different activities in the centre

and were graded for payment/job responsibility purposes not according to the

conventional grades, but into three bands, according to the level of multi-skill

competence reached. Of the many doctors who did sessional work in the

centre, the majority were consultant surgeons, anaesthetists and radiologists,

with only a few registrar grades, the centre not being regarded as a suitable

environment for junior doctors to hone their skills in. At the time of this

review, there were no GPs or staff grade doctors and none of the professions

allied to medicine, other than radiographers working in the centre (NHS

Estates, 2001; p.64-65).

None of this was achieved without considerable internal manoeuvring within

Central Middlesex Hospital, often in the face of strong opposition from

sections of the consultant body. But a strong management team, including

some influential clinicians and academics, was able to achieve the major

changes described in the preceding paragraphs. The motivations behind the

changes were complex, and included: the threat of the hospital’s extinction

unless something drastic were done to give it a unique edge; a visionary

desire to alter the shape of medical and surgical care, based on a local history

of strong interest in patient focused care (linked to a US organisation); the

expectation that the new unit would improve patient flows while reducing

costs; and the need to upgrade poor premises and facilities.

Nothing has been retrieved from the literature search that gives firm evidence

as to the clinical benefits or patient satisfaction at the Ambulatory Care and

Diagnostic Centre compared to a conventional unit. Nor has the search

identified published evidence about cost reduction or cost effectiveness.

Indeed, according to Sillince et al, the claims of 40 per cent predicted savings

which ‘did much to motivate Cabinet interest’, may have been exaggerated as

part of managerial strategy to convince opponents of the need for change

(2001; p.1428). One factor that may have affected financial forecasts is that

the original business plans for the Ambulatory Care and Diagnostic Centre

assumed a competitive internal market, with the centre attracting referrals

from many sources. The change of political climate meant that, at least

initially, referrals were mainly local (NHS Estates, 2001; p.62). The nearest to

a published independent evaluation retrieved was that produced by the NHS

Estates department (NHS Estates, 2001), which was generally very positive,

despite a long list of concerns about the ‘teething problems’, and an admitted

lack of evidence about the costs and benefits of the new service. The

evaluation was undertaken before the unit was ‘fully operational’, and too

soon for any extensive objective data to be collected. However, the conclusion

of this evaluation was that the Ambulatory Care and Diagnostic Centre had

achieved much, and ‘must be deemed a success’ (ibid; p.81):



It is very early days to draw any conclusions, and as yet there is little if any

evidence to support a claim that this model of care is more clinically effective

than the traditional model. This does not mean to suggest that the ACAD

[Ambulatory Care and Diagnostic Centre] is failing to live up to original

expectations. On the contrary, health care planners should await the

incontrovertible evidence that this is the most effective model of care for future

generations. Evidence-based care is a new science and it is only now that

intuitive practice is being proved to be the best practice in many instances. It is

suggested that intuitive implementation of ACAD may well prove in the future to

be best practice.

(NHS Estates, 2001;p.81)

The Ambulatory Care and Diagnostic Centre became an exemplar, and an

iconic innovation that could be used to legitimise service delivery reform

elsewhere. While no-one would claim that there are no benefits from the

redesigned services of the centre as it has become fully operational, objective

evidence of these benefits is not easily traced in the public domain. It would

appear that, to the extent that the TC programme is a direct descendant of

this initiative, health care policymakers and planners did not await

‘incontrovertible evidence’ of the benefits of ambulatory care, before rolling

out the innovation. It is worth noting, of course, that decisions to implement

new policies and practice without formal and timely evaluation – or without

attention being paid to the results of such evaluations – are not untypical in

the NHS (Bate and Robert, 2003; Sanderson, 2002).

2.1.2 The US ambulatory care model

Much of the inspiration for TCs in the UK also came from the US although only

occasional explicit reference was made to the US model. This influence was

often directly through visits and links with US centres, or indirectly by using

the Ambulatory Care and Diagnostic Centre as the basis for their design which

itself was at least partly inspired by the US model. Ambulatory care of a

similar mould that could also have been a partial influence could also be

found in other developed countries, including Australia, Western Europe, and

perhaps the polyclinics of Eastern Europe, but it was the US that was the

most frequently mentioned.

There are profound differences between the hospital system in the US and the

NHS in England, yet ideas and examples of innovation from the US have been

increasingly influential in NHS policy since the 1980s (Ham, 2005). It is

possible to see some of the key themes in the US, such as hospital

diversification and the decentralisation of services (Stoeckle, 1995; p.13)

being followed in the modernisation programme, including the development

of TCs and their immediate precursors in the NHS in England. It is therefore

necessary to dwell briefly on the US model, if only to highlight the extent to

which policymakers borrowed selectively from it when developing the TC

initiative.

There are of course strong common themes across health care in the

developed world. Since the 1970s, there have been broadly similar policy

debates and changes in health care organisation reflecting technological and

epidemiological developments and political, social and economic changes.

These have resulted in pressure, simultaneously, for cost containment,

particularly of hospital expenditure, and for services that are more responsive

to consumers’ demands. Among the results have been:



• a general trend of reducing the length of hospital inpatient stay

• a shift of service delivery away from inpatient hospital services to

outpatients or ambulatory-based delivery

• providers’ and policymakers’ interest in re-organising the process of

delivery of health care in ways which may break with established

professional and specialty demarcations, and which seek to increase

efficiency and manage risk through developing more formal protocols and

guidelines

• providers’ and policymakers’ interest in financial management tools, such

as prospective payment systems, and in increased competition between

care providers as a means of controlling cost and raising quality.

The pace and form of these changes have varied considerably between

countries. Therefore, the extent to which other countries have developed

organisational forms of delivery which can stand as comparators or even

precursors to the TC depends on many specific contextual features. However,

one point did emerge clearly from our initial scan of the international

literature: ambulatory surgery appears to have developed earlier and more

extensively in the US than elsewhere. This is not the place to enter into the

socio-economic background to this phenomenon in US health care, save to

point to a number of key features as to why and how free-standing

ambulatory surgery centres were set up and flourished in the US. We do this

in order to stress that although as we have suggested above there are

obvious commonalities with the UK, there are also marked differences.

Firstly, the rise of ambulatory care centres in the US has largely been in

competition with the traditional hospital, part of a general assault on the

‘citadel’ of the hospital, which many commentators describe as having been in

crisis since the 1970s. Secondly, initiatives in ambulatory surgery began to

have an impact on the pattern of surgical services in the US by the late

1960s, and increased exponentially following the establishment of perhaps

the most widely cited example, the Phoenix ‘Surgicenter’ in Arizona. This

pioneering centre had opened in 1970, two years after another such centre in

Rhode Island had opened but subsequently failed due to lack of financial

backing and/or recognition by the insurance industry for facility cost

reimbursement (see for example Berliner and Burlage, 1987). It seems that

ideas along similar lines were springing up across the US and continued to do

so over the subsequent years (Figure 1). This pattern of widespread

exponential growth over two decades is very different from the sudden

explosion of such centres following the central TC initiative in the UK in 2002,

when the US expansion had already run its course.

Thirdly, the ownership and motivation for surgicenters differed from UK TCs in

important respects. The Phoenix Surgicenter, for example, like most of those

that followed, was owned by medical practitioners who established it partly as

a means of solving some of their own frustrations about their professional

lives, for example by reducing on-call/night duties and providing suitable

day-surgical facilities. Doctors ran most of the US surgicenters to manage

elective operating schedules to ensure more predictable working hours, to

defend professional autonomy – particularly in the face of managed care

regimes and corporatisation – and to generate income (Pham et al, 2004).



Figure 1 Growth of ‘surgicenters’ in the US: 1971-1991

Source: Durant, 1993; Durant and Battaglia, 1993

Fourthly, the growth of surgicenters was associated with the growth of day

surgery (which in the UK had increased, albeit more slowly within hospitals);

with direct consumer demand; federal government and third-party cost

containment policies; overt competition between the different forms of health

care provision in response to cost-containment; and with the relative

attractiveness of surgicenters in terms of cost, planning and regulation and

doctors’ interests (for example income and autonomy under managed care).

To corporate investors in for-profit health care, they promised investment

opportunities that were exempt from state and federal attempts to limit

hospital expansion. To patients and insurance companies and other third-

party payers, they offered the prospect of cheaper facilities than inpatient

hospital wards. Such considerations, like many of the features in the way the

centres were consequently financed and organised, were very different from

the TCs in the UK.

In short, the US centres that served as a model for the UK programme were

very different in many aspects of their organisational governance, finance,

and raison d’être, even though they superficially resembled the subsequent

ideal of the TC in the UK. Yet certain of their key characteristics, such as

patient selection according to strict protocols, the separation of elective and

emergency care and an emphasis on reduced costs and patient convenience,

were selectively borrowed. This occurred despite the fact that there was

almost no formal independent evaluation of the clinical or cost effectiveness

of US ambulatory care and certainly none that allowed them to be applied

with confidence in the UK. Indeed our search of the literature revealed poor

evidence in the US about comparative costs between ambulatory surgicenters

and hospitals. During the controversy that raged over stand-alone surgical

facilities, the arguments for and against revolved mainly around three inter-

related questions, as formulated by Casalino et al (2003, p.57):

1 Do surgicenters provide the cost and quality benefits claimed for focused

factories?

0

200

400

600

800

1000

1200

1400

1600

1800

1970 1975 1980 1985 1990 1995



2 Do surgicenters have a negative (financial) impact on general hospitals

(individual and/or multi-hospital systems)?

3 Do surgicenters increase or decrease access to care?

Each of these questions is, in theory, amenable to empirical testing yet

Casalino et al (2003; p.60) noted the lack of such evidence when they were

writing and our literature search suggests a similar conclusion.

Surgicenters have been successful in the US, in the sense that their numbers

and the volume of services that they provide have grown rapidly over the last

30 years. However, how they work, and how their quality and performance

might compare with alternative ways of doing the same work is less easy to

establish from the published literature. Our review of the US literature has

found no evidence that specialist free-standing facilities had worse clinical

outcomes or would perform worse on other quality measures than

conventional hospital-based facilities. Indeed, all the evidence found indicated

that overall ‘quality’ and ‘outcomes’ were as good if not better in the

specialist facilities, but this evidence was not very extensive, robust or

generally adjusted for risk. There is some evidence that the case-mix treated

in surgicenters may be less complex, or comprise relatively more socially

advantaged patients. This does not, in itself, indicate that inappropriate or

unethical selection was taking place in the US. If fewer healthy patients were

being treated in the facilities with most extensive emergency back-up and

access to a wide spectrum of expertise, this might be entirely appropriate.

However, at least with respect to patients on the Medicare health insurance

scheme, the payment systems did not give extensive recognition to

gradations of complexity within diagnostic related groups (DRGs), nor to the

possible benefits of physicians having discretion in making referral decisions

for patients with a similar diagnosis but different severity.

The literature reviewed reveals that a highly politicised battle has been taking

place between different categories of health care provider in the US. This

battle has been not simply between for-profit and non-profit providers, but is

one in which the future of the acute general hospital is at stake. This is a

completely different scenario from the UK, yet a recurring theme that has

some resonance is the notion that competition from surgicenters (or TCs)

might threaten or damage the viability of hospitals. It is worth noting here

that this concern – which hints at problems about the market for both forms

of care – was selectively ignored by those borrowing features of the

surgicenters to design the TCs. This ‘blind spot’ about the extent of the

market for surgical work has since become a major problem for many TCs.

While there were limitations in the applicability and the levels of evidence

about US surgicenters, by 2000 the notion had gained momentum and

popularity among key UK decision makers. It was an innovation whose time

had clearly come.

2.2 Treatment centres and the NHS Plan

No central government references to diagnosis and treatment centres as such

have been identified in public policy documents before July 2000, but as we

have shown, there was by now considerable interest in the US and UK

precursors. The NHS Plan (Department of Health, 2000a) provided the



launchpad of the policy to develop this interest. This document, promising

both major capital investment and organisational reform of the NHS, and a

continuing increase in the proportion of surgery undertaken as day cases,

announced:

Special one-stop diagnosis and treatment centres [which] will concentrate on

performing operations, not coping with emergencies.

(Department of Health, 2000a; p.19)

More specifically the following commitment was made:

In partnership with the private sector we will develop a new generation of

diagnostic and treatment centres to increase the number of elective operations

which can be treated on a single day or with a short stay. These Centres will

separate routine hospital surgery from hospital emergency work so they can

concentrate on getting waiting times down. As a result of this NHS Plan there

will be 20 diagnostic [sic] and treatment centres developed by 2004. By then,

eight will be fully operational treating approximately 200,000 patients a year.

(Department of Health, 2000a; p.44)

Thus, the initial target was specific, but it was to be rapidly exceeded

demonstrating again, perhaps, that this was an innovation readily welcomed

by the NHS. By mid-2004, 29 diagnosis and treatment centres had been

opened, if not all fully operational, and some 80 TCs (run either by the NHS

or the independent sector) were forecast to be at some stage of

development/operation by the end of 2005 (Department of Health, 2004b).

The specificity of the NHS Plan, and the four-year timescale for first operation

of new capital projects suggests, as is the way with most White Papers, that

the new policy initiative was in reality already under development before its

official announcement (making at least some targets easy to reach).

Some features of the NHS Plan were particularly relevant to the TC initiative:

1 In addition to emphasising increased resources, the document was

replete with references to the need for organisational transformation of ‘a

1940s system operating in a 21st century world’ (p15). References to

redesigning services ‘around the convenience and concerns of the

patient’ (p15) to revising and reducing the boundaries between primary

and secondary care, reconfiguration of workforce roles, and the proposal

to establish a Modernisation Agency to support redesign of care around

patients (pp59-60) were employing the language of radical change

through ‘process-based organisational transformation’ (McNulty and

Ferlie, 2002). Although many innovations adopting this type of approach

to quality improvement in the NHS were underway before 1997 (as

evidenced by McNulty and Ferlie’s somewhat critical evaluation of a

business process re-engineering initiative in Leicester Royal Infirmary

which began around 1994), the Government appeared to have embraced

such approaches particularly warmly, notwithstanding some evidence

that changes achieved may fall short of those hoped-for (see for example

Ham et al, 2003). It may be worth noting that the NHS Plan contained

325 instances of the word ‘new’, 70 of ‘reform’, 12 of ‘radical’, and five of

‘transformation, which seemed to set a tone of modernisation and

innovation into which the TC programme fitted very clearly.

2 The NHS Plan presaged the increased involvement of the private sector in

both financing capital expenditure within the NHS and in supplying health

care for NHS patients. The development of independent sector TCs fitted



within a broader and politically controversial policy framework of new

partnerships between the public and private sectors in providing health

care.

3 Workforce redesign was seen as an intrinsic part of NHS service

improvement: hospital care was set to become more of a ‘consultant

delivered service’ (Department of Health, 2000a; p.78), in association

with extended roles for nurses, implying greater use of protocols. The

Ambulatory Care and Diagnostic Centre was commended for the

extended roles of therapists and for nurses’ work across the whole

patient pathway ‘providing ambulatory patients with real continuity of

care from admission to discharge’ (ibid; p.83). No reference was given to

support this commendation, nor has a published research-based

evaluation been found in the literature search.

4 A major policy aim of the NHS Plan was to ‘wage war on waiting’, and

TCs were seen as spearheading the attack on the waiting list problems

that had characterised the NHS for much of its history.

2.2.1 Reducing waiting times

TCs, together with the national implementation of planned booking of

appointments (see Ham et al 2003), and, later, the initiation of the Patient

Choice initiative (which sought, by the end of 2005, to offer patients waiting

more than six months for elective surgery a choice of provider - public or

private - including TCs) were central components of the ‘radical rethinking’

required to deliver the Government’s waiting-list targets for 2005 and 2008.

Within the Department of Health, the TC programme was set within the

Waiting, Booking, Choice programme whose role was ‘to bring about the

reforms needed to ensure NHS patients get fast and convenient access to

services’ (NHS Modernisation Agency, 2003a; p.2). Capacity shortage

identified by PCTs was a criterion for TC approval by the Department of

Health and additional activity (achieved or target) was the most frequent

measure of the benefits of the TC programme nationally and in local reports.

The inability of the NHS itself to expand capacity sufficiently to meet the 2005

and 2008 targets and ‘to clear real bottlenecks’ was the prime justification

given in public for turning to the independent sector to develop additional TCs

(see Section 2.3). The specialties with the longest waits were targeted by the

TC programme, for example ophthalmology, orthopaedics. By 2002, the

Department of Health identified a new role for the independent health care

sector in providing TCs, particularly emphasising the need for more rapid

growth of capacity than the NHS could allegedly achieve in order to ‘make a

real impact in time for delivering the waiting time targets in 2005 and

beyond’, as well as to ‘lead the way in innovation, productivity and speedy

response’ (Department of Health, 2002a).

The TC programme went beyond simply a substantial increase in capacity

and/or waiting time targets alone. The separation of elective from emergency

surgery, the encouragement of day case or very short-stay surgery, the use

of planned booking and pre-assessment clinics, the changes to skill-mix and

conventional divisions of labour that form the archetypal description of a TC

were all orientated to faster and more predictable throughput of cases. These

reforms were themselves informed by ideas about restructuring hospital care

that had been developing since the 1980s. Thus, while in press releases,



public relations and general policy documents, the TC programme was

overwhelmingly associated with the targets of reducing ‘waiting lists and

times’, the Department of Health appeared simultaneously to envisage TCs as

a driving force in the ‘modernisation’ process. For example, the programme

was identified as contributing specifically to the Patient Choice initiative and

to other NHS targets, such as reduction in outpatient waiting, increased day

surgery rates, reduction in cancellation of treatment, improving emergency

care access and improving ‘the patient experience’ (Thompson, 2003). The

health care policy community also explicitly recognised the potential of the TC

programme to increase competitive pressures on conventional NHS elective

care delivery, particularly through the envisaged role of the independent

sector.

It is worth noting at this point that TCs were just one of a number of health

care organisational changes and innovations implemented over this time

period. Section 5 explores in more detail the inter-relationships and effects of

a range of these on the TC innovation. At the same time that TCs were being

launched in the NHS a parallel programme of independent (private) sector

TCs was commissioned. This was part of a wider governmental push towards

involvement of the private sector in the delivery of care, presaged in the NHS

Plan but further developed over this time period. The NHS was also preparing

for the introduction of Payment by Results, a new system for reimbursement.

At the same time, Patient Choice and Choose and Book were being

introduced, including an electronic booking system. On top of this, the NHS

was introducing new information technology (IT) systems and working

towards the electronic patient record. It is into this dynamic, complex and

often conflicting world that the fledgling TCs emerged.

2.3 The development of the treatment centre programme 2000-2004

Progress was rapid by NHS standards, with more than twice the number of

centres being at least partly operational by 2004 than had been proposed in

2000. There are suggestions in the health care construction literature that the

pressure for rapid progress brought its own problems. For example, at a

conference in 2003, a speaker from a firm involved with some London TCs

was reported as saying that the politically-driven programmes (‘from now

until the next election’) caused difficulties because ‘clients [had] little

operational policy, no brief and no design, yet [need] to open in 30 months…

This leads to a danger of building the wrong thing in haste. And construction

has to start before design is finished, something we always used to try and

avoid’ (Wainwright, 2003).

All eight of the first wave TCs opened their doors on time (NHS Modernisation

Agency, 2003b). These were Moorfields Eye Hospital, University College

London Hospital, King’s College Hospital, the Royal Berkshire and Battle

Hospital, Weston super Mare, the Royal Haslar Hospital, the Ambulatory Care

and Diagnostic Centre and the Nuffield Orthopaedic Centre in Oxford.

However progress was not, apparently, rapid enough for the Government to

be confident of reaching its waiting list targets by the general election in

2005. In the NHS Plan, the involvement of the private sector in TC

development had been flagged as a possibility but its form left unspecific.



Many of the TCs run by the NHS were likely to involve some element of

private financing, as was becoming more acceptable in NHS service

development. But in 2002, an initiative to involve the independent sector as

direct providers of TC clinical services was launched, with the clear

expectation that, in the words of the head of the implementation team

responsible for this development that these independent sector TCs, ‘would

have ‘shorter set up times than the NHS is used to’ (Architects for Health,

2003). Since 2002, the NHS and independent sector programmes have been

pursued in parallel. There are reports suggesting that the expected scale of

the NHS-run TC programme under one financial programme was scaled back

in 2003 in favour of full independent sector TC commissioning (see for

example Anonymous, 2003). The development of the independent sector TC

programme is discussed in detail in Section 5.

Shortly after the arrival of a new Secretary of State for Health in 2003,

diagnosis and treatment centres (‘DTCs’) became treatment centres (‘TCs’) in

policy documents. No discussion of the grounds for this change has been

found in the literature retrieved. It may have reflected no more than a

preference for a shorter title in ‘branding’ this initiative, but there may also

have been other possible motives (see Section 5).

2.3.1 The role of the NHS Modernisation Agency

In line with the goals of the NHS Plan, the Department of Health established a

national NHS Modernisation Agency to promote service development within

the NHS. In relation to TCs, the agency had a specific (D)TC team which

developed extensive guidance and ran seminars and training events, and also

provided advice and support to local initiatives. ‘As soon as a new diagnosis

and treatment centre is confirmed, a member of the Modernisation Agency

diagnosis and treatment centre team will get in touch to offer as much

support and guidance as is requested’ (NHS Modernisation Agency 2003a,

p.6). The Modernisation Agency team produced an online guide for those

considering setting up TCs, and its website published information about the

national programme and some individual TCs (at www.modern.nhs.uk) as

well as a number of publications specifically on TCs. These included a

newsletter, Cutting Edge, aimed at those working in or developing TCs, an

overview of TCs as a new service model and a report on lessons from the first

wave TC sites, based on interviews with key informants (NHS Modernisation

Agency 2003b and 2003c).

Based on the experience of the first wave centres the Modernisation Agency

claimed that the biggest perceived risk to the success of TCs was not ring-

fencing them from existing operational activity (and hence encroachment

from emergency demands). They also stressed such things as:

1 the importance of planning and the amount of time needed to get an

operational plan together, and to plan beyond ‘the boundaries of the

diagnosis and treatment centre’

2 not underestimating the time and effort involved in modernising and

refurbishing existing buildings, and that redesign of patient pathways

was very time consuming (some used TCs as a starting point for wider

redesign process, others were pressurised to get doors open before

redesign was completed)



3 workforce planning - although recruitment could be a problem, the

improved working environment could give a TC an edge over other

clinical areas

4 advanced project management skills and experience in modernisation

and redesign would be invaluable

5 risk management should be addressed by building flexibility into

planning systems

6 the likely difficulty of getting the diagnosis and treatment centre up and

running within the given timescales, and the danger of deadlines being

met at the expense of redesign work, with insufficient time to prepare

the business plan

7 engaging within-site and local community stakeholder interest through a

comprehensive communications strategy, with a long list of the

stakeholders potentially to be engaged, but particularly clinicians, senior

trust executives, SHAs, and PCTs

8 making use of the Modernisation Agency’s expertise and networking

capacity.

2.4 Summary

The literature review suggests that TCs were an idea whose political time had

come. Despite the lack of a strong research evidence base, there were

exemplars or archetypes, largely derived from the US model of the

surgicenter, and realised in the Ambulatory Care and Diagnostic Centre,

which were substantially drawn upon to develop the model of TCs in the UK.

It is also clear that there were strong political and organisational drivers for

this organisational innovation, for example a role for TCs in addressing key

policy areas of waiting times and modernisation that were central to the NHS

Plan and NHS priorities. It is also apparent that the NHS Modernisation

Agency played a vital role in operationalising the policy idea and leading the

early development of TCs.

The next section looks at the initial conditions surrounding the eight TCs

chosen as the focus for our study.



Section 3 Initial conditions for innovation? The local internal and external milieus

The wide range of organisations that emerged under the banner of the TC

programme (see Section 1) should have come as no surprise. Not only was

the level of variation entirely predictable from previous experience of major

national programmes of innovative service design, such as NHS walk-in

centres, day surgical units and so on, but it had also been anticipated in the

original statements coming from central Government, in the guise of the NHS

Modernisation Agency and the wider Department of Health, and to an extent

in the NHS Plan itself (see Section 2). Such statements, however, implied

that the provision of an appropriate site would become clear from a particular

context, so that variation would arise from a rational analysis of such

considerations as the local need for particular services such as orthopaedic or

eye surgery, optimal geographical location or architectural configuration.

What we found, however, was a much more contingent emergence of local

solutions that depended as much on the local organisational politics, finances,

relationships and culture as it did upon any rational or systematic analysis of

health care needs. We borrow from C Wright Mills’ useful distinction between

milieus and wider social structures (1959; p.8) in the analysis that follows.

For Mills the personal troubles of milieu were separate from (but clearly

related to) the public issues of social structure. We use this idea of milieu to

denote the immediate environment and relations around the TC. In this

section we will therefore highlight the variety of organisational contexts or

what we refer to as the ‘internal milieus’ of our case studies and then describe

each of their external milieus. We use the term ‘internal milieu’ to refer to the

aspects of the TC and ‘host’ organisational structure and culture that we

identified as being particularly germane to the emergence and development

trajectory of the TC; ‘external milieu’ refers to the relevant wider context –

the relationships of TCs with their local and regional health economies.

Section 4 then goes on to describe how and why, given these milieus, the

trusts were motivated to open a TC and how their key actors negotiated their

respective resultant new TCs.

3.1 The internal milieus

What then were the key facets of the internal milieus of our case studies at

the time that the TC programme became relevant to them?

Site A, in a large metropolitan city, had already begun the process of

developing a stand-alone site for elective surgery by securing for itself a

separate budget and management structure that was seen as being ‘separate

.. a little directorate on its own’. The culture was one of opportunism and

entrepreneurialism, an approach that was quickly confirmed when the team

purchased a large existing private hospital on a long-term lease and set about

converting it into a TC that would come to be one of the largest in the NHS

programme. This purchase actually pre-dated the launch of the ‘official’ TC

programme. They appointed a hospital manager with a private sector

background to establish and run the new unit and a charismatic clinical



director to work with him. This group worked very much through their own

local professional networks to recruit clinicians from across the sector who

would be interested in working at the new centre. Bringing a mould-breaking

attitude of autonomy and ambition, their approach was to emphasise their

differences from the ‘normal NHS’. Although the new unit was very much a

part of the NHS, its location in former private sector facilities and the private

sector mentality encouraged by the senior managers was welcomed by staff,

many of whom had worked in private hospitals previously and had been

handpicked to join the enterprise. The staff consequently saw their

environment as small and friendly, ‘like a family’. However this led to

resentment elsewhere, in the trust and beyond.

They can do whatever they want to do; they can spend as much money as they

want to on agencies. So there was some jealousy and some envy, in terms of

their ability to use whichever agency in the country they wanted to get staff

through the day, because we must make a success of this.... The working

environment is better down there, they’re not ruled by the same set of

guidelines, cost control doesn’t seem to be an issue because you just get those

patients through the door, I don’t care what it costs you, make it work. So it’s

those sorts of things. And they were seen as a bit of a special case. And my

God, towards the end they became my special case. But I think that was part of

the problem, that they were set up as an entrepreneurial start-up business unit,

with, just go do it.

(Site A: trust manager)

As this quotation suggests, the ethos was strongly entrepreneurial, and the

management style one of a close-knit team forging ahead by overturning

conventions in order to blaze a trail for a whole new way of delivering

services quite distinct from the rest of the trust. The team therefore did little

to include ‘outsiders’ (other key stakeholders in the local health economy),

which led from very early in the life of the TC to a tension between the

entrepreneurial ‘go get it’ attitude of the senior protagonists, and the

resentful sense of exclusion among others outside the TC who were not part

of the high-flying ‘family’, but on whom the new organisation might

nevertheless need to rely if it were to flourish.

Site B was a contrasting scenario, a teaching hospital trust in a mainly

working class area of a large city. The trust had been underperforming for

many years, but a new chief executive and other recent changes were

beginning to turn it around. A key part of the turnaround had been to deal

with an overstretched emergency service, which had had major knock-on

effects for their elective services. So, for example, not only was their ‘trolley

wait’ in the emergency department unacceptably long, but the need to find

beds for those patients made them have to cancel operations at an intolerable

rate. Part of this picture was an exceptionally long average stay for

inpatients. The hospital was desperate to solve the problem of bed usage,

which had been undermining its overall performance.

The new chief executive was determined that by challenging accepted

practices and organisational myths that had long been part of the old regime

he would solve such chronic problems and take the trust to a position where

it could achieve its goal of becoming a foundation hospital. He had a

reputation for being performance-driven and hardnosed, and quickly brought

in new senior staff and ‘tried to get them to work corporately and cohesively

and almost kind of sweated the brains a little bit and got them to come up



with new ideas’ (Site B: senior manager). In the process he had gone from an

inherited top team with around thirty direct reports to only three, and this

had inevitably led to a sense of a widening gap between the executive team

and the rest of the organisation, and a feeling that managers were being

pushed to solve their own problems with little support other than the chief

executive’s backing (in spite of his avowed intention to be facilitative). He

constantly promulgated a set of core organisational values (stressing

openness, honesty, treating staff and patients with dignity and respect;

striving for excellence, listening and encouraging feedback and so on) which

he admitted might sound facile, but which he believed did help to shape

decisions. Some senior managers, however, still worried about a lack of clear

strategic direction; as one of them pithily remarked: ‘The ship at least has a

rudder again, but not yet a course to steer’.

Given their recently delegated powers and reinvigorated positional power, the

new team of clinical directors were beginning to challenge colleagues who

would have preferred things to stay as they were. They encouraged groups of

imaginative and innovative medical and nursing staff who were keen to

improve the service for patients and staff alike, and were already in some

cases seizing the opportunity of the hospital’s change in circumstances to

alter, very capably, the way treatment was delivered. There was a clear sense

developing of a core of like-minded people keen to change things. Using their

technical knowledge, a lot of enthusiasm and effective interpersonal skills,

this group of innovators was gradually spreading acceptance of these new

ways of practising. Without necessarily articulating or making explicit their

new ethos, this core team of people shared a range of ideas and values,

which included a ‘can-do’ mentality, a genuine desire to re-think the way

things are done; a determination to alter the patients' experience by being

more patient-centred; a desire to change professional boundaries and develop

roles that suited the patient's needs; capitalising on the enforced need to

make the hospital more efficient by using it as an opportunity to get people to

fundamentally rethink their practices, a recognition, and exploitation, of the

things that worry and attract doctors; a careful approach to push

professionals, with the grain not against it, as far as they could to change

practices; using prior personal professional connections to reassure people

that they could trust the changes; an openness to new ideas from other

centres; but little concern about evidence of effectiveness. All of these

approaches predated the advent of the TC and the Government’s

modernisation agenda, and Site B, like Site A, had anticipated the change

that came with that agenda. But while Site A was doing so as a separate

entity that stood outside and was trying to leave the host trust behind, the

movers and shakers in Site B were attempting to change the ethos of the

entire trust from within.

Site C had recently undergone large-scale organisational change associated

with moving to a new building. During the run up to the decision to open a

TC, there was an atmosphere of things perhaps not living up to promises. The

chief executive who had overseen the move to the new hospital had just left

the organisation and had taken a few of the key top management team with

him. Others also left shortly afterwards, leaving a some bitterness in the

organisation that careerists had used the move to the new site as a step on

personal career ladders and had not stayed to see the process through. Thus,

at the time that the TC programme was being considered (we were told),



there was no clear management strategy other than fire fighting, and

managers felt as if they were lurching from one crisis to the next, only able to

hit one target at the expense of another. For example the hospital might

mount a drive to limit the four-hour trolley waits in casualty but in the

process were taking their eye off the equally vital question of keeping elective

beds free for day surgery. Managers, not doctors, were managing the beds,

but were seen as not having a long term interest in what happened, as so

many of them seemed to be moving on. ‘They [senior managers] have no

vested interest in the legacy of what they do’ said one survivor, who had

predicted their exodus.

Reflecting this general situation, the early planning stages of this TC were

undermined by the fact that at senior management level new appointees were

still finding their feet and having to manage other big concerns alongside

planning the TC. There were vacancies in a number of operational roles; there

was a lack of clarity about who should be driving service change, and, we

were told, a tendency to take consensus decisions, which because they were

in fact rarely backed by the whole team often led to paralysis and inertia. The

unfocused managerial milieu within Site C, therefore, contrasted strongly with

the sharp and driven cultures of Sites A and B.

Site D, a small single specialty TC, was set up as a stand-alone unit and

jointly sponsored by a number of trusts in order to solve sector-wide

problems in the services for that specialty. Its management team had close

links with a similar centre in the US, and the management philosophy was

drawn very much from that mentor organisation. There was therefore an

explicit top-down attempt to ‘create culture’ at the beginning, using

organisational development teams and imported managers to promulgate the

ethos of a ‘high performing organisation with high performing people’. The

three key aspirational values as declared in a presentation given by the chief

executive were ‘one – caring for patients, families and staff, a learning

organisation; two – embracing continuous improvement, and pursuing

excellence; three – measures and outcomes’. Nearly 30 hospital consultants

from five hospitals were invited to work at the centre, where they could find

themselves being asked to operate on patients other than their own. However

it was the new nursing roles that initially characterised the TC, which was

intended to be nurse led, and to develop differently skilled nurses capable of

taking many of the roles traditionally performed by doctors and other

professions. The internal milieu at Site D was therefore similar in some

respects to A, in that this centre was highly driven by a strong and ambitious

management team that pursued a separate independent existence and

espoused the values of the private sector, and – as with Site B – used an

explicit set of values to shape the way the organisation was run. It is worth

noting however that Site D was housed in a wing of the parent trust and

relied heavily on the trust for ancillary services whereas Site A was a stand-

alone site and five miles from the parent organisation. This becomes

important when we consider the external milieu at Site D (see Section 3.2).

Site E formed part of a large geographically-dispersed trust around a market

town that had two acute hospitals. When ideas for a TC were first aired the

trust was in debt, with long waiting lists and unacceptable waiting times. It

had rationalised services by closing down the acute and emergency services

in one of the two main hospitals, resulting in local dismay and anger and a



sudden and unexpected move into the political spotlight. The partly-closed

site later became the chosen location for the new TC. The trust at this stage

was experienced as a disjointed organisation with prevalent feelings of

detachment between the trust’s sites and little sense of cohesion across the

trust. Frequent changes of personnel at senior trust management level –

including more than one change of trust chief executive officer during this

period – added to this sense of a fragmentary organisation with no clear or

consistent direction. Yet despite the disparate lack of focus, there was a sense

that the organisation was not risk averse but parts of it were able – severally

if not jointly – to foster entrepreneurship and innovation in order to

regenerate the trust. Moreover, there appeared to be a positive sense of

loyalty to the individual components of the trust, that is, the acute hospitals

and other outlying services.

Once the idea of a TC had been conceived and a project manager appointed,

this loosely connected organisational milieu of the trust allowed him the

space to construct an organisation within an organisation, ‘a semi-

autonomous business unit’ where his and others’ ideas could be tested and

encouraged to flourish. This individual provided not only clear leadership for

the TC but also a sense that the TC could offer space to focus ideas and

thinking. As the project planning got underway, the TC increased its

independence from the parent trust seeking to achieve status as a separate

entity rather than being fully integrated within the trust. This approach was

greatly helped by the fact that a TC was widely seen as a way to regenerate

the local hospital that had recently been closed; the scheme was therefore

strongly supported across the whole organisation. The project manager’s

vision for the TC was also an important motivating factor. His extensive

previous experience and knowledge of ambulatory care as well as his close

networks with others working in the TC arena (for example prior connections

to Central Middlesex Hospital’s Ambulatory Care and Diagnostic Centre – see

Section 2) gave him both authority and credibility. In both its design and its

philosophy, this TC was built around his acceptance of the Ambulatory Care

and Diagnostic Centre’s view that TCs are about ‘transforming patients’

experiences’ by focusing on ‘a wellness model’, in which the patient ‘isn’t ill

but just needs fixing’. His team supported this view and initially shared his

vision of the TC as having a rejuvenating influence within the local

community and providing a space for innovation, despite some initial teething

problems with timing and design. Under his visionary and innovative

leadership style, they were determined to make this into a showcase TC. In

short, Site E had strong transformational leadership and was functioning as

an integrated but relatively independent and thoroughly different, modern

organisation within an organisation.

Site F was a large trust within a major city. There was a pragmatic, ‘can do’

action-driven culture of opportunism, innovation and risk-taking. It was, for

example, at the forefront of electronic patient records, the new wave of

acquisition of private hospital premises and later of foundation hospitals:

One of the nice things about working for this trust is that there is that capacity

to do things and to drive things forward ahead of everybody else.

(Site F: hospital consultant and manager)

However, the imperative for rapid action often took precedence over analysis,

which was reflected by the lack of detailed planning and organising, in this



case, around the TC. Typically, strategy and planning was driven – like other

aspects of management in the trust – more by intuition and assumptions than

facts. Senior managers were accused of being attracted to the ‘flavour of the

month’, but having a low boredom threshold, moving rapidly on to the next

project:

It’s as if these are the things [the trust] want to do – okay we want to buy a

private sector hospital for the NHS. We want a DTC [diagnosis and treatment

centre] to play with. So now we move on to the next thing.

(Site F: middle manager)

The trust also betrayed a strong culture of mistrust and adversarialism, as

though everyone else in the local health community were an antagonist who

sent them ‘rubbish’ patients, withheld information, tried to deflect resources

from them, or otherwise slowed them down in their drive to innovate. This

pervasive ‘them and us’ attitude, manifesting itself as derogatory stereotypes

of key personnel in the local health community, or by caricaturing ‘the centre’

of the NHS (that is, the Department of Health and the Modernisation Agency)

as mediocre, risk averse and lacking in innovative ideas, had led to

longstanding tensions. The trust preferred to steer its own path, paying as

little attention as possible to the rest of the health economy, which led to its

being seen by neighbouring organisations as difficult, and as bypassing them

in its relentless quest for innovation and change.

Internally, the trust was strongly segmented into relatively autonomous

departments and professional groups – the word ‘tribalism’ was often used.

For example, although there were some highly effective charismatic medical

managers, many doctors and managers held traditional attitudes of mutual

mistrust and antagonism wherein doctors might typically characterise

managers (who in their view were often transient and inexperienced) as

failing to consult and communicate, while the managers might characterise

the consultant body as a recalcitrant and powerful block to change. As a

senior clinical manager involved in the planning of the TC put it:

There was a lot of unhappiness with the consultant staff, mainly relating to

communication of what was going on. And they felt that all this [the diagnosis

and treatment centre] had been done administratively without any discussion

whatsoever with the consultant staff..

(Site F: hospital consultant and manager)

Individual departments or directorates showed little interest in matters

outside their immediate purview. Other departments could be left to sink or

swim so long as one’s own domain was still flourishing. If another group was

running into political or financial difficulties, Schadenfreude was a more likely

response than co-operative assistance. In short, Site F was a trust

characterised both internally and in its external relations as an ambitious,

risk-taking, competitive, individualist, seat-of the-pants success, riven with

tensions.

Site G was a relatively small trust that in many ways mirrored the sense of

faded grandeur of the adjacent town, a backwater that needed to pull itself

into the mainstream if it was going to thrive. It maintained a strongly

hierarchical organisational structure, where in essence everything went

upwards to the director of finance and the then chief executive. These two

had a long working partnership, predating these particular roles. There was



clear sense from the staff that personal contact with this top team was a key

to getting things done. The smallness of the trust made this possible; there

was a lot of ‘popping into the office’ to talk to the chief executive. A

traditional doctor-led hierarchy was also a key feature of the culture, coupled

with a small management staff:

[This trust] has got one of the lowest management costs of any trust in the

country and I think it’s been under-managed. If you speak to some of the

medics here they’ve also said that to me. I nearly fell off my chair because

that’s the first time a doctor or a consultant has ever said that to me. It’s been

under-managed and a lot hasn’t happened because there hasn’t been the

management equipped to do things.

(Site G: manager)

The trust was seen from outside as rather ‘traditional’ – even backward.

There were thought to be too few managers trying to cover too much ground

and using very traditional paper-based administrative methods, which meant

that they were usually slower than other trusts in delivering requirements to

the higher levels of the NHS.

The initial thinking about the TC was therefore led by a small team of middle

managers variously seconded to this task. They mainly did this work as

overtime on top of other professional/managerial duties. This small part-time

team had – and created around them – a real sense of team working and a

common purpose. In many ways it initially functioned like an ‘action learning

set’ (Revans, 1998), using the TC project to develop both their own personal

learning and skill development but also that of the organisation. The people

involved were clearly committed to the project and almost jingoistic in their

subsequent recollection of working in the final weeks and days to ensure that

the unit opened on time. One of the foundation myths of the TC, highly

evocative of the organisational culture, was of the chairman of the board

coming in to put up pictures on the walls and getting told off by a cleaner,

who failed to recognise him, for making dust. Thus within the very traditional

history and structure of the trust, there were people there who were keen to

get behind the change and push it forwards. However, they later each

returned to the jobs they had been doing before their involvement in setting

up the TC, and the skills they brought to the project were not developed nor

built upon, reinforcing the view that this was not an organisation ready to

recognise, reward and develop good staff. Site G, in short, was a small town

trust with an old-fashioned NHS administrative culture, under-managed,

subject to the medical hierarchy, and reliant on individual enthusiasm for

change.

Site H comprised two trusts with very different cultures that had recently

merged. As part of a wider reconfiguration of services locally, the smaller

trust, where the TC would eventually be based, was to become a site for

elective activity only. Staff at this smaller trust had traditionally been

perceived by staff at the larger trust as being less empowered to make

decisions and of working in a more top-down organisation. Those staff who

were being asked to move from the larger to smaller trust were generally

reluctant to do so (as the first paragraph of the quotation below illustrates).

Staff at the smaller trust perceived the ongoing reconfiguration as part of the

inevitable takeover of their hospital by their larger neighbour (see the second



paragraph of the quotation), and these tensions were to have a direct effect

on the development of the TC.

Some of us have worked here for 20 years and we were kind of hoping to retire

working in [Site X], but we’ve accepted that if we want to stay together as a

team, then to [Site Y] we have to go. … Whilst we’re glad that it’s being built on

[Site Y], they’ve got their own worries about the two teams merging because

even though we’re only eight miles apart working in similar hospitals, we do

have very different approaches, and merging the two teams is going to be

difficult ... I think probably the nursing staff in [Site X] are used to decision

making and taking on board more responsibility. I think the [Site Y] girls have

relied on their managers to tell them what to do and not to question why they’re

doing it quite so much...

...[T]hey just have a completely different approach to us and I do think it stems

from management and also, when the two hospitals merged, most of the senior

managers on [Site Y] either resigned or retired. So, most of the senior managers

that are around now were originally [Site X] managers and I think [Site Y] have

always felt that it was a [Site X] takeover. So that naturally breeds its own kind

of hostility. But I have managed the team over there for about four years and I

think they have made inroads, but it has been hard and I myself feel like it’s a

[Site X] takeover really.

(Site H: nurse manager)

The doctors, who were a strong force in both sites, resisted many aspects of

the plan: the idea that only elective surgery might happen in Site Y; the need

to travel between the sites- about 20 minutes apart by car; the prospect of

working in a new unfamiliar environment; the expectation that they would

have to cede control over the booking system for their operating lists and so

on. None was originally keen to champion the idea of a separate site for cold

surgery.

I’m having a lot of problems with the medical staff about it… I think underneath

it all they just don’t want to change. They like working here, they don’t want to

work there. But they’re coming up with all sorts of objections, and this is the

eleventh hour.

(Site H: senior manager)

In fact I’m already aware of heels digging in the sand to say, we [doctors] are

[Site X] based, we can’t possibly go to [Site Y] because we’re very busy people,

and heels are dragging along the lines of, we would really prefer to have our

endoscopy services all in [Site X] and not have them part of this nice new

endoscopy service. We’re just working quietly subtly along the lines of digging

our heels out of the sand at the moment.

(Site H: consultant)

Nursing staff and managers with a nursing background were better disposed

to the merger and the idea of using one of the sites for elective surgery than

were the doctors, but neither they nor the more senior managers felt

empowered or found it easy to push for change:

I wasn’t supposed to hear, but they [nurses] are happy, in between the

grumbles…. we’ve been encouraged as team leaders to have meetings with the

clinicians, but it is quite difficult. We don’t know what we can offer them

financially and we both feel it will just end up as a shouting match. So we’re

trying to get them when they’re on their best behaviour and get a few clinicians

into one room. They’re all going to want to out-shout one another and it wouldn’t

be sensible for either of us to chair a meeting I don’t think. I feel we would go

down rather than up in their estimation.



(Site H: nurse manager II)

Unlike the other trusts, the chief characteristic at Site H was a post-merger

‘digging in of heels’ by a consultant body who were unwilling to accept the

need to change their practice, and whom the managers generally felt unable

to persuade easily. There was also a sense that while some individuals were

positive about the TC there was a general lack of ownership by staff.

This sketch of the internal milieus initially suggests little similarity between

the cultures of the sample sites, all of whom had decided to open a TC. There

was a range of management styles, aspirations, relationships and pressures

that characterised each of the eight sites. However, one factor that unites all

the sites was, albeit variously expressed, a sense that this particular

organisational change was timely and necessary, and with this a ‘can do’

mentality and the presence of at least some core ‘champions’ who were keen

to implement this innovation. Thus at Sites A and E we saw

entrepreneurialism, Site B was ‘looking to change’ Sites D, F and G were

‘driven’ and held together by a common purpose. The exception at this early

stage was Site C which was characterised by weariness with change. It is

worth noting that this was one of the later sites to open and that this

weariness was explained by the relatively recent move into a new hospital

building. Later in the development of this TC a dedicated TC project manager

was seconded to oversee the project and the internal milieu at this site began

to resemble more closely those of the other seven sites in our study. Before

examining in Section 4 how these situations affected the emergence of the

eventual TCs, we turn to a description of the external milieus of the sites.

3.2 The external milieus

It will already have been apparent, that Site A – the newly acquired private

hospital premises with ambitions to provide a single specialty service across a

wide metropolitan area – had very little support and indeed endured

downright hostility from most of the local trusts. Moreover it was doing very

little to engage the key stakeholders across the local health economy. As a

senior manager in the SHA told us:

Yeah, it came completely out of the blue. Nobody knew anything about it. I still

don’t know whose decision it was or whose idea it was or who was the driver.

Because of that, it raised immediately antibodies all over the place.

(Site A: senior manager)

The antibodies were all the stronger because, in a sector where most of the

NHS was already struggling financially, a six figure sum had been top sliced

from all the local PCTs to fund the new unit. Complex financial arrangements

were set in place that neighbouring trusts were predicting (rightly as it turned

out) would disadvantage the hospitals that were expected to send their

patients to the new unit. Nearby hospitals felt that this new development

meant that not only was the host trust, a teaching hospital, taking their more

complex and interesting patients, but now its unit was going to take their

routine elective patients too. Some saw it, therefore, as a takeover bid

destined to undermine other local hospitals in the whole area. The way in

which the surgeons were handpicked from among the network of the unit’s

senior team was an added irritant:



So they had no choice. So here we are, here’s [the new TC]: use it! Now, if

you’re sitting in a hospital … and none of your surgeons have been chosen to

be part of that, you’re going to go, ‘I don’t think so’.

(Site A: senior clinical manager, host trust)

For Site A, therefore, the TC was being brought into a fairly hostile world,

which would inevitably make life difficult for it. This was a stark contrast to

Site B, where the local health economy was hardly aware of, and almost

unaffected by, the notion of a TC within that site. Site B, one of two main

university hospitals and somewhat the junior partner, was in a region that

had been relatively poorly funded and lacking in region-wide strategic

thinking. The region was now making amends with several major planning

initiatives most of which were based on strong aspirations to improve, and

shift the emphasis towards, primary and community care. There was,

however, little regional strategic thinking about hospital provision; instead

there was a sense of all the local trusts carving out their own space and their

own futures.

We recognise that what happens in the NHS in [this region] is that every trust

has resolved its own problem

(Site B: senior manager)

In keeping with this philosophy, early discussion about opening a TC was

largely an internal matter concerning the rearrangement of patient care in

order to tackle some of the internal problems of chronic bed shortage. While

necessarily involving the regional authority and local SHA to approve the bid,

the trust was able to plan and open its first phase TC without any

involvement from local PCTs, trusts and GPs, to whom the new unit was

almost invisible. Thus, although the trust managers wanted to move ahead

quickly to implement what was almost entirely an internal initiative – and

moreover one that had direct support from the Department of Health and the

Modernisation Agency since it would not only help achieve the targets but did

involve a strong element of ‘modernisation’ – the SHA and region took several

months to satisfy themselves that the bid was genuinely within the spirit of

the TC programme. Mutual relations at this time could be described as

smooth if slightly impatient. However the second phase plans to open a fully

fledged TC three years later along the lines of the Ambulatory Care and

Diagnostic Centre became ensnarled in a growing tussle between the push

towards rationalising services across the region and the need for the trust to

solve its own performance problems and maintain its role as a leading

teaching hospital in the city. At the time of writing, more than five years after

the first phase was opened, the Phase 2 new build is still at the planning

stage.

Site C, still recovering from its recent move to a new hospital, had an unusual

but important and influential external link, namely the (private sector)

contractor who had built the new hospital, and who would need to be involved

in the new TC. The relationships with the builders and project managers for

this part of the TC project were in essence a re-run of those built up during

the recent transfer to the new hospital – but on a smaller scale. The obverse

of this was that the trust was also the focus of a great deal of (hostile)

attention from the NHS trade unions coupled with some adverse local political

action.



Relations between the host trust and the TC were good. Indeed within the

host trust, as will have been clear from the description of the internal milieu,

the TC was just one of many management agendas, so that the TC’s internal

structures were closely, often inseparably, linked with those of the trust. For

example, bed planning discussions about the wards in the TC were integral to

discussions about bed configuration across the whole trust. At all the

meetings about the TC the key senior/middle managers also held

trust/hospital posts, which inevitably led to a ‘whole system approach’.

However it also meant that the TC planning process suffered from the lack of

necessary focus and attention until (at the SHA’s suggestion) a project

manager was appointed, allowing the TC project to acquire more consistency

and drive. As this intervention suggests, relations with the SHA seemed good;

it played an important role in helping to shape the project management while

the TC plans were being developed. As for the local commissioners, nearly 60

per cent of activity came from a single local PCT; both geography and history

made Site C the natural provider for this PCT. However, two neighbouring

PCTs had recently become dissatisfied with the performance of the providers

they usually used. They therefore agreed a contract during the planning

phase of the TC to remove their contracts from that hospital and bring them

to Site C, thus promising to supply around half of the expected TC patients.

This agreement formed a key part of the original TC plans.

Site D was intended to provide a service across several trusts, but was

nevertheless a subunit of one of them. The TC managers did not favour this

arrangement and from the start wanted to be ‘completely stand-alone’. The

result was tense compromise: the beds were completely ring-fenced and the

chief executive of the new centre described himself as not working for the

‘host’ trust directly. Officially the TC was designated the status of a Division

by the host trust, distinguishing it from a standard service directorate and (as

stated in the clinical governance documentation, for example) ‘recognising a

degree of quasi-autonomous operational independence’. Nevertheless the TC

was reliant – reluctantly – on the host trust for such services as human

resources and finance. Senior staff at the TC were continually troubled by

what they called ‘the politics of being hosted by another institution’ that did

not understand the principles of the TC and what it was trying to do in the

way of reshaping patient pathways and staffing. They wanted to ‘employ our

own… start as we mean to go on’, ‘starting from scratch’ they often talked

about ‘throwing away the rulebook’, and wrote their own job descriptions

even for human resources and finance staff so that they could be shown the

different culture/way of working the TC had. But rather than being allowed

the freedom to go forward, they felt held back by the trust, who seemed to

frown on their innovative ideas, constantly demanding justification for the

new ways of doing things and delaying progress. The TC very quickly ran into

major problems when trying to recruit clinical staff to new roles in line not

only with the modernisation agenda of nurse-led patient pathways but also

with the Government’s Agenda for Change document (Department of Health,

2004d). Yet the trust ‘went ballistic’ because this contravened their staff

gradings and the TC ‘had to come back into line’.

Some TC personnel felt that the host hospital was not merely questioning

innovative practices but was positively cynical about the venture,

apprehensive about accepting the risk of responsibility for the TC, resentful

that the TC was poaching some of the best staff, envious that it was receiving



special favours, and secretly hoping it would fail. Clinical governance was one

of the foci for this underlying tension with the host trust, who saw the TC as

inherently risky because it was doing things unconventionally; not least

perhaps because it was intended to be nurse-led which had already raised a

few eyebrows. To some extent these concerns were shared by some of the

external stakeholders such as the PCTs who were expected to provide

patients, and who felt their concerns about risk management and governance

were not being properly addressed. Exacerbating these problems was the fact

that although the TC had been long in the planning and had secured the

support of most – if not all – of the local chief executives, in the months

before it opened all of these senior supporters had gradually left the

organisation. Many of the central features of the TC (being nurse-led, almost

self-autonomous) were less well understood, or approved of, by the newly-

appointed senior managers. The chief executive of the new centre felt he had

to sell the concept to all these key stakeholders all over again.

The several PCTs for which the TC was to provide the specialist service had

other misgivings too. Although they varied considerably in their views about

the short lengths of stay of postoperative patients, some were very concerned

that the early discharge (based they said on a system in the US that had the

benefit, not here present, of a step-down facility), would put too much

pressure on primary and community care. There was a lead purchaser from

among the PCTs present at the meetings, but discussions were impeded by

the lack of continuity of PCT representatives, who changed from meeting to

meeting. Thus, despite the TC’s intention to be ‘meticulous’ in its

communication and involvement with the client PCTs, the resulting links were

not very satisfactory and many deeply held concerns remained unresolved in

the eyes of key external stakeholders.

The local SHA and workforce confederation, however, were supportive of the

direction the TC was taking. Finally, the TC had ambitions to bring in patients

from beyond these PCTs and their four local trusts by becoming a major

supplier of services under the Patient Choice scheme; initial negotiations

suggested that this would be a fertile source of patients. However this was

never to materialise.

At Site E, before any real thoughts of creating a TC, the trust had been

catapulted into the political limelight through the local community’s action to

initially fight the hospital closure and, when that had failed, to get acute and

emergency services reinstated to the area. Despite the turbulent relationship

with the local community the trust had generally good relationships with the

PCTs and the SHA. As the project began to get off the ground the new project

manager fostered these harmonious relations. The local PCTs and the SHA

signed up to the idea of creating a diagnosis and treatment centre on the site

of the closed hospital, seeing its potential for reducing waiting times across

the health economy and also the possibility of offering some acute services

for local people to use.

The TC was seen to fit in very well with the local development plans... as it

provides the opportunity to have more activity up in [Site E] – releasing

resources, freeing up pressure, I suppose, at the main acute hospitals.

(Site E: senior manager, local PCT)

The TC manager made a point of including representatives from the local

health economy (its three local ‘partner’ PCTs and the SHA) in decision-



making through their membership of the TC’s clinical board. All parties

recognised the benefits of forming close working relationships:

It’s a step into the unknown. If we approach it positively and constructively,

then I think that it could be a significant resource. If we get lost into all kinds of

inter-organisational arguments and bickering, then we could very quickly lose

the benefit that it would have to offer.


The three local PCTs, who soon represented their views through one lead

chief executive, also established a degree of flexibility within the

commissioning process as activity levels were shared across the three PCTs.

They welcomed the potential for the TC both for patient choice and for

improved services:

It does provide another opportunity for choice. It’s a separate location for choice,

which is very helpful, and I think that my GPs have recognised that that is a

significant additional opportunity for speedy access. I think that’s the plus.


…we can guarantee you access and we can guarantee that complication rates

and infection rates will be significantly lower than if you went into what you

would perceive to be a traditional hospital.

(Site E: senior manager II, local PCT )

However all was not straightforward: the most local PCT, which shared the

hospital grounds, tried (ultimately unsuccessfully) to ‘take over’ the running

and ownership of the TC. This experience was later to predispose the TC to

broaden its patient base from much further afield as a way to protect it in

future from local competition or predators. The SHA saw the TC as ‘fulfilling

the new consumerist model of care espoused by the government (care when

you want it, in a good environment)’ and were keen to champion its use

beyond the neighbouring PCTs; indeed key SHA staff were constantly

reminding them that the TC would be an option for their patients. When later

this began to happen, the TC, although valuing their contracts in terms of

filling space and providing revenue, did not accord these outlying purchasers

such close ties as the more local PCTs; none were represented on the clinical

board and the TC manager either dealt with each individually or through a

brokering trust (for example one PCT in another county bought services from

the TC through their local acute trust). These more distant PCTs, on whom

the success of Site E might partly depend, had mixed feelings about the

usefulness of the TC – later on some found it to be a useful addition to their

facilities.

The treatment centre provides the opportunity to have more activity … releasing

resources, freeing up pressure, I suppose, at [our] main acute hospitals …

(Site E: PCT chief executive)

But others were less positive, feeling that they were disadvantaged in

negotiations related to price and case-mix and, as a result of this, preferring

to use services closer to home. One director of finance who initially contracted

with the TC for a small amount of services (in the region of ‘a score of

patients a month’) for his acute trust and a PCT 35 miles away chose, later,

not to renew the contract for a second time preferring to use the more local,

more extensive, cheaper provision that had been developed.



But the main problem we’re having is the relatively restrictive list of procedures

and the prices they charge making them not particularly attractive and certainly

no more attractive than some of the [local] private sector. Also, the private

sector, even if they’re slightly more expensive [may] do a volume deal.

(Site E: senior manager representing neighbouring acute trust and PCT.)

During the planning phase strong ties also began to develop between the TC

and the Modernisation Agency. The project manager drew heavily on what he

saw as the Modernisation Agency’s emerging ethos for a TC – one in which

care was based around:

…making smoother journeys for patients, taking direct referrals for elective

surgery, focusing services around patients… and providing diagnostic services

(Site E: diagnosis and treatment centre project manager)

From the start, the Modernisation Agency regarded Site E as one of its model

TCs and indeed later on in the evolution of this TC this relationship became

even stronger. For example as the TC developed, the project manager and

the matron/clinical manager gave presentations and supported poster

displays at learning events run by the Modernisation Agency. The agency’s

liaison officer for Site E described it as ‘very much along the core

characteristics that we try to promote, and they work very hard to achieve

that, more so than many of the other treatment centres. I think there are two

advantages that they’ve got - one is that they’ve got (a project manager)

there with his experience which has helped, and the other thing is the fact

that they were one of the first mixed speciality treatment centres to open’.

Site F – a major teaching hospital – was not in a happy relationship with most

of its external stakeholders who resented its competitive, even predatory,

approach to service planning and provision. However, patients came to the

hospital from a very wide range of sources, which left the trust less reliant on

any particular local PCT (in contrast with, say, Sites B and C). The many

meetings in which the trust liaised with key local stakeholders necessarily

covered a large agenda, and the TC was rarely mentioned. But the

adversarial/ethnocentric attitude of the trust may also have led the trust

managers to keep their cards close to their chest as they were planning the

TC, and certainly the external agencies felt that the trust had deliberately

excluded them for the decision-making:

The treatment centre... slightly bypassed conventional NHS planning and a lot

of that is down to a very entrepreneurial chief executive they’ve got at [Site F].

But the perspective I had was that [Site F] was extremely opportunistic and

lobbied directly, if not at Number 10 level, then certainly at Department of

Health level and really bypassed health authorities and general planning

measures, and negotiated directly with the politicians and senior civil servants

about the establishment of the [TC]. So I think it was a bit of a surprise to

people that [Site F] had acquired this [TC] and didn’t particularly fit in with the

normal capacity planning processes that you’d expect people to go through

before discovering the new service entity. Presumably the PCTs were just

coming into being then as well and I think you’ll find they were pretty much

bypassed as well in the discussions.

(Site F: manager, SHA)

The PCTs did indeed play very little role in commissioning care at that stage

and negotiations, such as they were, were mainly confined to the SHA and

the Department of Health. Indeed when the local PCT did later get more

involved, the trust simultaneously, and without the PCT’s knowledge,



negotiated via the Patient Choice initiative to get additional patients at a

different rate of payment, leading to a flurry of accusations and counter-

accusations of spurious billing and ‘double counting’ of patients that were

symptomatic of this lack of trust between the commissioners and the trust.

Site G’s dealings within the local health economy were mainly with five PCTs,

and relations were generally very good. The key local PCTs were satisfied that

they had input into the planning of the TC, and the SHA were supportive, too.

Indeed the latter played an important role in expanding the original idea of a

day surgical unit and suggesting doubling the capacity and applying for

funding from the TC programme. This was despite some concerns – which

had to be taken account of – that the new facility might weaken the position

of a nearby teaching hospital.

Finally, at Site H the main aspects of the external milieu that affected the TC

concerned its host trust. The trust, due to the internal politics of the two sites

(see internal milieu above) had wanted to steer clear of a ‘hot’ (acute) and

‘cold’ (elective) site hospital by opening a TC on both sites, but the external

bodies such as the region and local PCTs disagreed. Indeed the plans for the

TC were affected very early on, before an outline business case was even

begun, by a strategic overview of services being carried out at the regional

level. Once the idea for a single TC had been agreed within the regional

strategy, the region and the two main local PCTs had little further

involvement; they regarded the setting up of any such unit as largely an

internal matter, although the two PCTs did each contribute a five figure sum

to improve staffing in the areas of patient activity that were expected to be

covered by the new unit. This lack of involvement may have been because

the new unit was considered simply to be an integral part of the hospital

trust. Funding, staffing and governance within the TC were part and parcel of

the overall strategy for its host trust – including clinical governance even

when the teams of surgeons working in the TC might be brought in from

overseas to carry out the operations. This also meant, however, that the TC

was subject to internal management reorganisations and financial

retrenchment when the trust ran into financial difficulties. These financial

setbacks in the host trust resulted in a significant scaling down of the planned

operation of the TC, and frustration among those responsible within the TC

for delivering the intended improvements and modernisation of services. It

also resulted in the transfer of some of the more specialist areas of TC work

into direct provision by community clinical services run by the PCT.

This examination of the external milieus of our eight sites did not reveal a

unifying theme. The range of relationships described here appear to run along

a continuum, with Sites A and F characterised by hostility and adversarial

relationships with most of the major stakeholders within their external milieu,

through to E and G which appeared to experience more harmonious and

constructive partnerships with the major players (albeit at E this was

underpinned by political necessity). In between these there is apparent

disinterest (Sites B and H) and a more mixed picture of tense, or at least less

helpful, relationships (for example between the local trust partners at Site D,

and with PCTs at C) alongside other more supportive stakeholders.



3.3 The importance of milieu

The internal and external organisational milieus around our case study sites

were clearly influential in the initial development of these eight TCs. In

particular we have seen how important the internal milieu was in providing

the necessary leadership and a supportive ethos (even if this was sometimes

confined to a small inner team). The key relationships driving the TCs’

development were rooted in local historical and cultural contexts, but

nonetheless from these milieus emerged players/actors who would take the

TC forward.

Given the policy rhetoric about strategic planning and the pivotal role of PCTs

in shaping health care provision (espoused in the NHS Plan as well as other

statements from central Government [Department of Health, 2000a; 2001;

2002b]) the lack of serious engagement of many of the TCs with their

external milieus was perhaps surprising. As our data show sometimes it was

not simply that the external stakeholders ignored these local initiatives; they

were hostile from the planning stage onwards. While during this initial phase

of development the nature of the relationships with external stakeholders

appears to have had little real effect on the emergent TCs (who appear to

simply ‘get on with it’), as we will see the external milieus took on greater

significance at later stages in the development of these TCs.

Having noted the importance of local context, champions and relationships,

we also explored the roles of some of the key local players whose actions

helped to shape the development of the TCs, for it was such local actors who

moulded the rationales for and against the innovation into the eventual TCs

that emerged.

3.4 Opportunists, pragmatists, idealists and sceptics

The rationale for TCs (set out in Section 2) promulgated by the government,

the Department of Health and the Modernisation Agency, may seem a priori

to be clear: reducing waiting lists and modernising care pathways. However

as we have seen, the local justifications were the result of more complex

‘negotiations’ between different groups or ‘players’ within each site, each of

whom interpreted the innovation differently. At each site there were ‘contests

of meaning’ as different understandings and definitions of what a TC was and

meant for the organisation were played out in the early phases of the

development of the TCs. We are interested in these contests of meaning

because they reveal how TCs were understood, but also the powerful

dynamics which motivated the development of these sites (to which we turn

in Section 4). We anticipated that in looking at the motivations for developing

a TC we would see evidence for a negotiated order (Strauss et al, 1963;

Strauss, 1978) that is, in the presence of formal organisational goals (for

example the TC policy) there would be transactions, disagreements and

bargaining between actors which would shape the resulting organisational

structure(s). In the event we found little evidence for the types of clear cut

inter-professional negotiation described by Strauss et al (1963) but as a way

of making sense of what was happening at each of the sites we were able to

delineate four key groups of players who seemed to have a role in



determining the fate of the innovation. Of course, our fieldwork, much of

which was interview based and therefore reflected events through the eyes of

the informants – can provide only some indication of the ways in which the

decisions were played out.

We characterise the four ‘ideal type’ groupings, which help to illuminate the

nature of the stories presented to us to explain the development of the case

study TCs, as opportunists, pragmatists, idealists and sceptics. We are

reassured that other literature makes reference to similar groups. For

example Traynor (1999) identifies four comparable groups in his analysis of

managers in nursing. Indeed the NHS Modernisation Agency (2002) has

produced a report about the role of sceptics in change management. The four

groupings can be depicted as follows:

• Opportunists saw TCs as a chance to do something (rebuild, expand,

renew), often something that had already been planned or was

developing.

• Pragmatists focused on local, practical issues, notably delivering

appropriate care and meeting the required performance targets via the

TC.

• Idealists enthusiastically embraced the broader vision and underlying

philosophy of TCs such as the ‘modernisation agenda’ of professional

reform and re-engineered patient pathways.

• Sceptics viewed TCs as transient fads or, worse, as risky endeavours, and

they therefore resisted top-down attempts at change. They urged caution

and tried to temper the extremes of idealism or opportunism. Through

these perspectives, powerful players in each site interacted to shape the

development of individual TCs.

In several of our sites, opportunists used the TCprogramme as a way to get

capital funding to finance projects they had already been hoping to

implement for some time. At Site G for example, a project group had wanted

to expand day surgery in their trust. Following the announcement of TC

funding and with some encouragement from the SHA, the project group

developed a bid for a TC mainly as a vehicle for the day surgery unit they had

thus far been unable to realise. Site B was another example where

opportunists seized the day, recognising that the TC Programme was a

chance not only to provide a new facility that would relieve the overstretched

hospital’s crippling bed shortages but also to refurbish a costly building, long

regarded as a millstone that was under-used because it was tied up in an

inappropriate trust facility. Establishing the TC in the building would resolve

these twin problems of an underused building and an overstretched inpatient

service. At Site A, the purchase of another hospital by the NHS was a chance

that the opportunists had already grabbed and which immediately formed the

basis of the TC when the programme was announced subsequently:

A little bit of it was opportunistic it’s fair to say, the hospital, just down the road

that had come onto the market. Splendid facilities and at a time when in terms

of capacity we were pretty tight it’s fair to say.

(Site A: senior manager, host trust)

The ‘pragmatic’ perspective was about the business of simply getting on with

delivering a good service. For pragmatists, while care delivery might well be

improved in line with the ideas enshrined in the modernisation ideal, the



main intention was not to rethink practice but to streamline or otherwise

upgrade it. They recognised that the TC afforded an opportunity to do so, or

to be recognised as doing so, as the following quotes illustrate:

We’re starting to say to them, we’re going to shine, you always have done but

now the spotlight is on, so carry on doing what you’re doing in the way you’ve

done it and the excellent service you provide, but now people are going to

notice.

(Site E: nurse manager)

The TC gives me and people in this trust an ideal opportunity to do it properly,

to set new standards, to change communication and staff attitudes.

(Site C: middle manager)

But, as the second quotation suggests, that opportunity could easily spill over

into a more idealist frame of mind. In the case of Site B, there were many

pragmatists who used the innovation as a way to further develop services

they were already providing. But the TC also allowed a group of innovative

idealists to ride the wave of modernisation and push others, including the

pragmatists, towards radically new ways of working:

Someone said ‘essentially we’re moving [the existing day surgery unit], and I

said ‘no way, that’s not what we’re doing. What we’re doing is we’re moving

[that unit], but we’re recreating a different way of working and doing that so it

provides a great opportunity to do that. I think what it will do as well is a new

facility will encourage the shift around making day surgery happen, and I think

why we’ve got to do that is a lot around the booking scheduling agenda.


It’s the future, isn’t it? Booking, day surgery, modernisation of pathways,

workforce development is all the way, that’s the development of day surgery

really. I treat the [TC] as the priority on my list because that’s where I intend to

go. In the next 10 years that is where day surgery is going, definitely.

(Site B: nurse manager)

This nurse manager and the middle manager quoted below, archetypal

idealists both, had their effect partly by running a training course on process-

mapping (getting staff collectively and systematically to rethink from first

principles the processes to which patients were subjected) which was led by

enthusiastic innovators associated with the TC. The course was opened up to

wide range of hospital staff, large numbers of whom attended and spread the

ideas. In this way the TC became a vehicle for redesigning the delivery of

care and engendering an important shift in mentality.

I have to say, and I like this modernisation. I enjoy going in and looking at how

people are doing things the same way, let’s get round a table and see how we

can do it better. I do like that.

(Site B: middle manager)

At Site E, a senior manager, who could well be classified in this context as an

idealist fully wedded to the ideology of modernisation and ‘transforming

patients’ experiences’, was enormously influential in establishing an

innovative TC:

I think there was a real want to change the way services were delivered here,

that was the project manager’s whole role – he wanted to provide something

very, very different – that was the future of health services and that’s what he

was pushing for.



(Site E: senior manager)

Opportunism, pragmatism and idealism were not the only possible responses

to TCs at the local level. Some actors were more risk-averse, tempering the

plans of the idealists and opportunists, or possibly just more jaded about yet

more change in their NHS.

I have to say that I’ve only ever spoken to a few of the consultants there, and I

get told well, it’s a complete load of rubbish, it’s another bloody target we don’t

need and go away. And I’m quite sympathetic. I know it’s not easy, but at the

end of the day I have a job to do and it’s not my fault that this… you know, I’m

just here to do a job. If I get blamed for everything that the Government do that

the consultants don’t like.

(Site B: manager)

As one respondent scathingly told the interviewer when asked about the TC:

You come up with all these fuzzy words. I don’t quite understand… well it’s a

day case unit, isn’t it?... The trend is to identify within the whole morass of the

health service bits that can be cleaned, identified, counted, costed and get on

with that. Day surgery, treatment centres coming in, the cancer work being

centralised, not just because it’s a good idea clinically to have the expertise but

because it’s a way of dealing with it that is more uniform. The worry is what’s

left and how that’s going to be managed.

(Site B: hospital consultant).

At Site C this frustration with change was also located at the local level. A

senior manger reflected on the huge organisational changes implemented in

the previous few years and commented on change fatigue:

I think one of the comments that one comes across within the organisation is

that whilst people are up for the challenge, it’s something that yet again [that] is

new ... There’s also planning fatigue in that they’re only a year away from

having achieved a significant planning feat... [this] new treatment centre comes

swiftly on the back of the new acute hospital site and therefore people, to an

extent, are probably worn out .

(Site C: senior manager)

Sceptics often suspected that the rationale for TCs went beyond – or even

had little to do with – the philosophy of TCs as portrayed by, say, the

Modernisation Agency (Section 2), or as championed by the idealists. For

example, some sceptics saw the separation of emergency and elective care as

simply another unwanted organisational change imposed by the Department

of Health or as part of broader (party) political manoeuvring:

On one level I see it [the TC] as cutting down waiting lists, taking the workload

off other hospitals; on the other level I see it as a government initiative to get

elected at the next election.

(Site A: middle manager)

Sceptics were often concerned with the impact of the TC on other areas, such

as risk management or models of care delivery:

There are clearly great difficulties. Some trusts and consultants in those trusts

quite legitimately, in my view, feel that if they’ve seen a patient in outpatient,

investigated them and discussed an operation with them, it is very demoralising

to see that patient go up the road and have a stranger do their procedure.

[….]You have very un-joined-up patient care which may certainly crunch your

numbers but I think leads to consultant dissatisfaction, professional

dissatisfaction, poor morale and ultimately, I think, to poor human relations.



(Site G: hospital consultant)

Within all the case study sites, the initial conditions that we described earlier

in this section allowed these four types of player to set about arguing the

case for and against developing a TC. A crucial part of those discussions was

a discussion of the potential reasons for having a TC at all. It is to these

motivating factors for opening a TC that we now turn in Section 4.



Section 4 Taking up the challenge? The local motives for opening a treatment centre

Section 3 has outlined the internal and external milieus of our eight study

sites. These local contexts and relationships influenced and shaped not only

the decision whether or not to bid for a such a centre, but also the planning

processes that led to its opening, and the initial form taken by each of the

organisational innovations under study.

Our eight case study sites include some of the earliest ‘trailblazer’ TCs as well

as sites which were part of the later ‘first’ (which actually followed the

trailblazers), second and third waves of the national TC programme. The

process of bidding for a TC thus varied between the sites. Later sites typically

prepared an outline business case, and/or a strategic outline case to be

approved for funding, before going on to prepare a full business case for the

TC. There appears to have been an expectation from the Department of

Health that such plans would be developed in consultation with all the

relevant parts of the local health economy, in line with the usual planning

processes in the NHS. However it seems from our interviews with those

responsible for bidding for TCs and from other key players in the locality that

some of the earlier sites did not go through such rigorous, systematic

processes.

To some extent the planning process was closely linked to the initial

conditions described in Section 3, such as the existing relationships with

stakeholders like the SHAs and PCTs. But the variations in the planning and

evolution of the TCs were also shaped by the original motives for opening

such a unit.

Our fieldwork revealed a very wide variety of motivators leading up to the

decision to apply to establish a TC. These motivators helped shape the

resulting organisational innovation, and were played out in each site as the

local ‘pros’ and ‘cons’ were discussed and sometimes contested as the plans

for each TC took shape. What becomes clear is that this was never a case of a

local site taking an innovation clearly delineated by another agency – be that

the Department of Health, the Modernisation Agency, a pre-existing model of

a TC, or one local champion’s vision – and straightforwardly bringing it into

being. In none of the sites was there a simple process of implementing a

standard, existing innovation. As described by organisational researchers and

theorists (Kanter et al, 1992; Pettigrew, 1985; Van de Ven et al, 1999;

Helms-Mills, 2003) innovations undertake their own journeys, changing and

evolving as a wide range of organisational and other contingent forces mould

them into their eventual shapes: TCs were no exception.

In this section we describe the motive forces that led to the establishment of

our case study TCs, grouping them into three main categories, which we call

‘improving quality’, ‘improving quantity’ and ‘improving kudos’ (by which we

mean their standing in such matters as external profile, reputation, influence,

and income). These categories comprised a number of motivators such as the

desire to improve patient experience, to reform professional roles and

attitudes, to meet performance targets, or to improve organisational or



personal standing. Many of these motive forces were at play at the same time

within a single site – sometimes pulling in the same direction, sometimes

opposing each other – since inevitably key actors and factions held differing

views and aspirations for their TC.

The interplay between the motivations to improve quantity, quality and kudos

was therefore difficult to discern. At Site H for example, it was clear that

something needed to change if the host organisation was to meet its

performance targets, and many believed that a TC was just such an

opportunity to improve the efficiency and the quality of care. Yet some

clinicians were arguing that it was clinically inappropriate to focus the work of

one of the hospitals entirely on elective care, a view seen by managers as

masking a reluctance by the consultants to countenance changes that might

negatively impact on their well-established working conditions and practices.

At Site F, motives related to improving quality (for example by modernising

care pathways) were even less visible, save perhaps as an ambition of a small

group of modernisation enthusiasts; the question of enhancing quality by

reforming professional roles and attitudes was certainly seen by most of the

managers to be a bridge too far. But improving the profile of the trust, in

particular consolidating the financial and political standing of the hospital,

was so much to the fore that opening a TC was an imperative. At Site B, on

the other hand, there were a number of influential people who were ready to

use the TC as a way of breaking the mould of traditional professional practice

and modernising care (improving quality) and moreover there was a clear and

almost unanimous agreement that bidding for a TC would be a pragmatic way

to help rectify failing performance levels such as waiting times (improving

quantity). The opportunity to solve a longstanding problem of how best to

utilise one part of the hospital premises and the need to ensure that the trust

continued to have a high profile in a planned redistribution of hospital

services across the region (improving kudos) also added to the urgency to

acquire funding for a TC. As all these examples show that the various motives

underlying the emergence and development of each TC, whether acting in

concert or in opposition to each other, differed not only between the sites but

also within them.

4.1 Improving quality

4.1.1 Patient care

There was little doubt that one of the main motivators in the local tussles

over TCs was the chance to improve the patient experience even, as we saw

in Section 3, for the sceptics. Some – in particular the idealists and

pragmatists – were fired up by the reports of good practice that were buzzing

around the clinical and managerial networks of the NHS and by the broader

drive towards modernisation of care processes that was given greater force by

the NHS Plan (Section 2). These developments all conspired to give at least

some of the key players in each of our sites the incentive to use the TC as a

means to do something innovative and exciting that they hoped would lead to

radical improvements in the delivery of elective care. Often this was

described, especially by enthusiasts, as ‘new ways of working’:

I think there’s something there about it being built around the patient….

ultimately for me, it’s about getting that standardised care so that every patient



is getting the same sort of process. They’re getting a booked service, they’re not

going to get their operation cancelled, they’re home with their friends and family

that night. It’s those sorts of things. I think overall I feel it’s about reducing

dependency …..They’re not sick, they’re just well people with a problem, and I

think it’s about creating that culture of non-dependency. You come in and you

have a problem fixed and you go home, but I think still making the

improvements for staff though will be really important.


It’s getting the clinics designed right so you’ve got the multi-professional clinics.

You now have the one-stop services for patients so that you’ve got a scoping

facility for instance for the urologists and gastro probably as well, type things.

Equally, it’s having appropriate radiology in there. .... People talk about these

treatment centres as being a sort of modern, new way of working and so on.

Can you characterise for me what you understand by that..? What I would like

it to be is that the patient can be booked in efficiently. I would like to have a

proper administration for the outpatients. I would like patients to come up and

go to a quality facility where they will get their bloods, breathing tests,

whatever tests they need and, for some patients, I would organise for them to

have the test before they see the doctor so that when they see the doctor

they’ve got the results, not come and see the doctor then go and have the tests

and come back some time later.

(Site B: senior hospital consultant and manager)

For me personally it is about all the other stuff that the national programme

sings about, really, and that, as I said, it’s not the catalyst but it’s the

opportunity to bring new people into post and it creates a new opportunity to

work differently and work more smartly… do we want to open Monday, nine to

five, with Saturdays, do we want to open term-time only and close for school

holidays. I need to be really convinced if we don’t go for the closing in school

holidays option because I just feel that it’s all very new. We know that people

for elective surgery tend not to want to come in over Christmas and the summer,

so why don’t we just make a bold decision and say, that’s what we’ll do, we’ll

close two weeks over Christmas, a week at Easter, close for two or three weeks

in the summer. Private hospitals do that.

(Site C: senior nurse manager)

At Site H the new ways of working were summarised as follows in the outline

business case:

At times of peak emergency demand… the requirements of emergency workload

take precedence over elective workload, and both day case activity and

inpatient elective work needs to be rescheduled. Apart from impacting upon the

trust’s performance in terms of activity and waiting times, such instances are

crucially distressing and disruptive for the patients concerned, and their family

and social/work relationships. There needs to be a greater protection for this

planned, elective workload to prevent these circumstances arising in the first

instance and the [diagnosis and treatment centre] provides that greater

protection by separating the ambulatory and short stay elective workload from

the emergency demand … the development of [diagnosis and treatment centres]

requires considerable re-engineering of standard processes and procedures

currently in use for dealing with patient referrals, appointments, admission

dates … it is recognised that that development of [diagnosis and treatment

centres] provides opportunities to strengthen and blur the interface between

primary and secondary care services.

(Site H: outline business case)

Site D anticipated similar benefits in patient care including improved

responsiveness through reduced waiting times; improved outcomes through

development of critical mass and sub-specialisation; greater predictability of



process and care allowing greater levels of preparation and smoother

transfers; and the development of services closer to home, especially post-

acute rehabilitation. They also expected to achieve direct clinical benefits

such as better patient management, the development of specialist expertise

in an environment conducive to change, enhanced training opportunities,

better quality control and the more efficient use of consultant sessions.

Elsewhere, for example in Site F, some senior staff intended to modernise

services , even though this aspect was not necessarily a major feature of the

planned TC and, as the second quote below shows, was somewhat modest in

its ambitions:

I think the main developing factor was to try and bring in some additional

income to the trust and to join in a quite progressive modernisation theme. I

think the original idea was around using this site as a pilot for modernisation

that could then be rolled out trust wide and that hasn’t happened at all but

we’re hoping it will happen. There are a number of initiatives we want to look at

including skill mix reviews, just doing things differently, shortening the length

of stay, increasing the day case rate – so we want to explore a number of

initiatives that we can actually pilot on behalf of the rest of the trust and pre-

assessment is going to be the first such pilot.

(Site F: senior manager)

I do believe in what the [diagnosis and treatment centre] has to offer, its

innovative factors, my old modernisation thing. I like to be involved in new

ways of doing things. You know, many things are happening in the NHS that

should be done so much better than that. And, of course, the main philosophy

behind the [diagnosis and treatment centre] is actually putting the patient first.

Everything is built around that, not just paying lip service to it. If we can make

their health experience much better then it’s got to be a good thing … For

example, I’ve been trying to encourage one of our H grade sisters to be

innovative, and the latest thing we have been talking about is replacing the two

off-duties for the two wards with one person on at night working across the two

wards – being more creative within our establishment.


The desire to modernise at this site might have been strengthened by the

need to survive in an increasingly competitive local health economy in which

other trusts, and even more so the private sector, were driving the need to

improve patient experience in order to attract referrals to the trust.

I think the real driver for change is going to be the independent sector much

more than the NHS treatment centres. I don’t think NHS treatment centres are

radical enough. When the independent sector are truly up and running I think

they will offer a truly different sort of treatment centre. I think the other thing

which shouldn’t be underestimated is the extent to which the threat of market

entrants from the independent sector galvanises NHS activity. Nationally all

sorts of things which are very difficult, if not impossible, within the NHS have

become possible because of the threat of independent competition.

(Site F: SHA manager)

But as we describe below (Section 4.3.1) any idealism of the modernisers at

Site F, even if it had been given extra impetus by the perceived threat of

increased competition, was tempered by concerns of a more pragmatic,

political nature.



4.1.2 Reforming professional practices

The new ways of working had a number of spin-offs that some regarded as

more important than the actual change to the configuration of local services.

Foremost among these was the longstanding desire to reform the way

clinicians do their jobs – not only in terms of their day to day management of

patient care but also in the way they related to the organisation as a whole.

TCs that entailed new patient-focused care pathways were an innovation that

had the potential to alter fundamentally the roles, responsibilities and

autonomy of nurses and in particular doctors. For many in the health service

this seemed an opportunity to break down barriers, alter the range and

combination of skills of a whole new generation of nurses and professions

allied to medicine, and possibly even alter professional power-relations.

Perhaps above all some viewed it as a way of bringing the hospital

consultants to heel at least in the way that they organised their services, but

preferably also in the way they behaved as members of the organisation as a

whole (a matter of organisational citizenship). This attitude is illustrated in

the following three quotations:

Involving [the] independent sector has the knock on effect of breaking

consultants’ cartels – which is how [Site D] is often portrayed from outside.

(Site D: manager)

They’re not keen on changing practice, but we’ve got to move forward and

develop the service so that when we get the [TC], we’ll be prepared for it. So

what we’re doing is a lot of preparation work, so slowly we’re targeting each

different consultant. We’re picking a particular procedure, targeting the

consultant and saying well, we feel in our experience these patients are ready

to go home the same day, and if we put this, this and this in place, would you

be happy. What we’ve found is they are happy if you make changes slowly.


[The TC] is not exactly a Trojan horse, but more like an enabler to try out new

ways of working, different types of care pathways which in a non-threatening

way might introduce new flexible ways of working, including pre-booking of

patients (which some – but not many) consultants are very resistant to.

(Site B: manager)

As this last quotation shows, some sites were explicitly using the TC to reform

the way in which clinicians across the whole trust delivered services (and

indeed felt strongly that stand-alone TCs – like Site A and others nationally –

might fail to do this):

Look not only at the treatment centre, but its functional relation to the other

departments is quite useful to see because that will give you an impression of

the opportunities to look at how the patient pathway works from outpatients

through diagnostics through treatment centre through inpatients, and how

patients may flow through the whole. So, that leads us maybe in two years time

to this concept of the whole hospital treatment centre because so many things

are interrelated, and that’s the opportunity that this treatment centre probably

gives us.


I think the treatment centre, because it’s a new build, it creates a new

opportunity. The trust has learnt from the fact that they built this new hospital,

we moved in, and we didn’t change our processes. We transferred old

processes into a new build. It was a huge job moving here. It’s easy to reflect

and want to do it differently but I think the learning has been that for the



treatment centre we do want to try and do things differently.... So, it creates a

double set of challenges. It’s not about just making what happens in the

treatment centre right and best practice and leaving the activity in the general

hospital area behind. We’ve got to make both areas and move forward together.

(Site C: manager)

These views contrasted with the views, say, at Sites A, E and especially D

which saw their strength in trying to maintain as much separation as possible

from their host trust. They wished to introduce new ways of working that they

felt were impossible in what the TC visionaries saw as an irredeemably

hidebound host trust (see Section 3.2).

For some things it is appropriate for [the host trust] and the treatment centre to

stand alone. We don’t want to stand in the way of innovation because it is an

opportunity to be forward-thinking and do things differently.

(Site E: senior hospital consultant)

Site D based its ideas of professional reform on its direct links with a

surgicenter in the US, at which leading clinicians spent time learning the US

methods of care delivery, and with which the TC had a contract for team

building work and other advice.

Yeah, I went over in February, this year, to [the US site]. The main thing that

struck me was the whole culture over there – that everyone is very a flat

structure, not like it is with NHS. And it was really bringing that back and trying

to incorporate that [ethos] into here. And also mainly the pre-assessment and

pre-education lectures are fantastic and create a patient system like that –

which is something we’re trying to do here with two advanced practitioners for

pre-assessment here.

(Site D: senior hospital consultant)

The feeling among such converts was that such an approach to changing the

whole way in which professional care is organised could only be done away

from the main hospital, starting with a clean sheet as it were, and free of

close ties with established custom and practice.

TCs also provided – as an integral part of the prevailing modernisation

agenda – the opportunity to change the professional roles of clinicians other

than doctors. In particular, many TCs hoped to broaden the skills of nurses,

operating theatre staff, professions allied to medicine (for example

physiotherapists) and occasionally also radiographers. At Site G a senior

nurse manager described how they were looking at new ways of using

assistant practitioner roles and about moving nursing staff between the TC

and other areas to increase their skills and range of competencies. People at

other sites talked about other changes in skill mix:

I think new ways of working that I would like to see come in is that we would

work much more in the operating theatre with surgical assistants. I think we’ll

have to reorganise fairly radically how we run pre-assessment clinics and try to

involve junior medical staff.

(Site C: senior consultant)

We’ve increasingly got people able to order x-rays, who are extending the nurse

prescribing arrangements, the roles in theatres … they’re changing quite

significantly. We’re looking increasingly at practitioners in different areas to

take on the role of junior doctors. The health care assistants are taking on quite

a bit of the work of the qualified nurses, the nurses themselves are taking on



doctors’ roles. We’ve got night nurse clinicians who do virtually everything that

the junior doctors can do so we’re making quite a lot of progress.


I’d certainly still like to multi-skill the [TC]. I believe in multi-skilling and I

always have…. I think it could be far more efficient if we did that. If we got rid

of the, ‘I’m the scrub nurse and I’m the ward nurse.’

Interviewer: What steps are being taken to break down those barriers?

Well we have changed quite a few things where nurses go and work on the

ward and I say nurses – I use that as a generic term – and HCAs [health care

assistants] have certainly been brought in to do various tasks which they never

used to do before. I certainly wouldn’t want to see people say having an

untrained person either taking a theatre case or assisting the anaesthetist

because if things go wrong they can really go wrong and you need someone

who knows what you’re doing and what you’re up to and, equally, I think it’s a

quality issue. I’m not saying you can’t train people up to do things. I think you

can.


The question of how these new roles and arrangements such as clinical

assistants and nurse-led units were eventually developed – or not – will be

dealt with more fully in Section 6.

4.1.3 Promoting training and research

Although rarely mentioned at the start of the TC programme, training was to

become an issue once TCs had been established. (Various media and

professional groups voiced concerns about the independent sector TCs and

their impact on training [BMA, 2006a; Lane, 2005]; see also Section 7.2.3).

In the early days there were some who saw their TC as an opportunity for

training clinicians – an opportunity linked to some extent to the ideal of

changing clinician behaviour through the example of the new facility and its

new ways of working

More recently we’ve been able to hone in a little bit on what the training might

be and … what’s seeming to come to the fore is that maybe a lot of the

education provision is not going to be feeling-based, it’s attitude-based. It’s

behavioural-based. It’s getting people to think with a different mindset of, how

can we do it, rather than, it’s not possible to do it. So, that’s what’s parked at

the back of my mind that we’re going to have to do some work on but, as I say,

I’m waiting for more clarity about what that actually looks like.

(Site C: trainer)

Although rarely given as a motive for opening a TC, its potential to enable

more efficient training, and indeed research, was sometimes mentioned. This

is interesting given that one of the arguments against TCs was that as

factories for routine work they would militate against training and

development:

Interviewer: What do you see as the clinical opportunities offered by the

treatment centre?

Hospital consultant: I think it’s volume, really, and it’s the chance to do large

volumes of work and, hopefully, at a high quality. With that then one would

hope you’d get the added benefit of becoming even better in terms of research

and training. I think as a personal individual the possibility of doing more of the

particular work that you want to do so you can become more specialised.



Interviewer: One of the critiques of the treatment centres is that many of them

aren’t going down the training research route but you see that quite differently.

Hospital consultant: Well, we do because if we, for example, wanted to do a

little trial comparing something against something, if you’re only doing 250

things a year, it’s actually quite hard often to show a statistical difference,

whereas if you’re bumping it up to 500 a year, then all of a sudden you’re

starting to get very large groups of patients that you can do things with. So, we

perceive this as an opportunity of doing high volumes and therefore being able

to do some meaningful research. Training, I think, is a more difficult issue

because one is always conscious of the fact that the model for a treatment

centre is really about volumes and so on but given the high volumes there is, I

think, still a possibility of training albeit one would have to think about how

that’s done in terms of it’s not a case of leaving the registrar to get on slowly

with a hip replacement but perhaps doing four in a day and he’s involved in a

little bit of each one so you don’t slow down the whole process terribly much

but at the same time he has done a bit of every operation. So, there is a chance

to do that.

(Site C: hospital consultant)

So, we could see that in the long run if the thing ever came to fruition it was

going to have an impact on medical training. And, the trusts were reasonably

concerned about the impact it would have had. And [Site A] was an extreme

example because they were going to put in all of their elective stuff which

meant there was no elective experience back at the ranch, which meant that in

the current regime the college and deanery would have stripped the posts out.

This is where we thought they were perhaps not really recognising the full

extent of the issue, they were saying ‘let the consultants come and bring their

juniors with them and they’ll get the experience that way’; which is okay for

[Site A] but back at the host hospital that would have left big holes in their rota.

(Site A: workforce confederation manager)

But with an eye to the future what we thought was, well, if we’re going to

operate that system, if we’re going to look at the rotations and use [Site A] as

one placement on the rotations we better put some more juniors in. So, what we

were able to do, to deal with the working time directive, most trusts in the end

adopted doctor labour solutions. So, we did take the opportunity to put more

recognised training days into the [regional] pool so that, should this situation

come to pass, where trusts actually were having a lot of elective work taken out

of them, which would impact on the juniors we would have the capacity to

restructure the rotations. Now, that’s why we’ve done it and that’s what’s at the

back of our minds. I think we’re a long way from persuading the STC {specialty

training committee} etc. that it needs to take a fundamentally different view of

the way they structure rotations. At the moment they don’t see the need to and I

know what will happen, once it actually starts to bite and they being to get

worried about what kind of experience people are actually getting in a particular

trust, then they’ll start thinking about these issues and they’ll begin to take it a

bit more seriously, which, for me is a little bit frustrating but that, I recognise is

life.


4.1.4 Optimising local premises

There were various ways in which concerns about current facilities provided

the motivation to open a TC. These fell into three main categories: optimising

bed use; a chance to upgrade existing premises; and a way of paying for a

new building that was in any case needed.



All three were apparent at Site G, where the trust saw the opportunity not

only to improve its bed management, but also upgrade a building, establish a

separate unit and moreover increase income in one fell swoop:

The whole idea that if you batch groups of patients and operative types

together, you can be much more efficient. Out of that came a proposal that this

void in our new building could very easily and quickly be converted into a state

of the art day case unit. We wanted part of that for our own work but there was

obviously a vacancy there [for outside work] and that’s what we did.

(Site G: hospital consultant and manager)

This desire led initially only to a stop-start discussion as various designs were

talked about, including a stand-alone facility. Some of the early key players

went out on fact finding trips to see how other hospitals did day care. They

came back with ideas and became agitators for getting a day care unit. The

hospital then received a windfall legacy from a local philanthropic source

which, after some wrangling with the local League of Friends, allowed the

building of an extension to the hospital. The trust decided – possibly

influenced by a chairman whose general philosophy was ‘let’s just get on and

do it’ – to build a two-storey ‘shell’ and fill it later. This proved decisive:

having an empty space that could become a day care unit was then a strong

enabling/motivating factor for the TC bid. The PCT were also keen to open

such a facility as a solution to an under-capacity problem, recognising the

opportunity to commission additional work from a day care unit. However the

catalyst for developing this idea into a TC was financial opportunism edged

with political expediency:

We tried various routes to do that, to get the funding, to get it off the ground,

and we eventually ended up with the support of the strategic health authority,

who had a bigger route, through the [diagnosis and treatment centre]

programme.

(Site G: senior manager)

The main precipitating factor came finally from higher up the NHS hierarchy:

At that time we then heard that the government for the first time started to talk

about overseas treatment teams, so that would have been in 2000. I quickly

spoke to a few people in the Department [of Health] and said to them, ‘is there

any money for this? If you want we’ve got a place for the overseas teams to

operate, no problem, but I need some capital as well, it’s the capital.’ And, I got

told there wasn’t capital. So, we put in a bid [for the TC]. Then I’m not quite sure

exactly how it happened in terms of the osmosis but they came back that while

we hadn’t got money for overseas treatment teams but that our bid had been

very well received because we could have this thing up and running quickly

and we could use these teams. And the government was going ahead and

wanted new treatment centres and they wanted them open tomorrow. … And,

at the same time as we had the crisis in [another local trust] … The conversation

I had with [a civil servant at the Department of Health] was quite bizarre. He

said, ‘I hear you can open a day case unit treatment centre quickly?’ I said, ‘Oh

yes, we’ve got the shell, we could do it.’ ‘How quickly could you do it?’ ‘How

quickly would you like it?’ Well, the Prime Minister wants it tomorrow to sort out

the [neighbouring trust] problem, he wants all these two-year waits sorted in 18

months.’ ‘In five-and-a-half months we’d probably do it if you give us the

money; two to two-and-a-half million, that’s what we need and you have the

treatment centre, I can open and we’ll bring the overseas teams in and we can

do it.

(Site G: senior manager II)



The result of such a serendipitous but urgent melding of central and local

motives led to a precipitous and nerve-wracking deadline that was met with a

derring-do spirit by the whole team. But similar considerations also affected

other sites, if at a somewhat more leisurely pace.

At Site H the case for the TC to upgrade poor quality premises was explicit:

Apart from performance issues, the ENT [ear nose and throat] and

ophthalmology services are provided from the [host hospital] site … the smallest

and poorest quality site owned by the trust … this site is scheduled for closure

and disposal.

(Site H: outline business case)

But the fraught local politics tempered this case for new facilities with the

need for utmost caution to avoid the pitfalls that came from the factional

vying between the two hospitals that were being merged.

At Site C clinicians were complaining that inpatients, surgical day cases and

medical outliers were all jumbled together, making it difficult to protect day

case space and enable the day case unit to work efficiently. The TC was a way

of absorbing the inpatient load and enabling the effective ring-fencing of day

case work:

Since we’re moved here we’ve just been totally unable to run day surgery.

During the summer, okay, but just during the last winter the day surgery has

been filled up with inpatients.


When we were preparing, really, for the move through to the new PFI [private

finance initiative] hospital the discussions had already started at the senior

management levels with regard to bidding for a treatment centre. I think there

were perceived to be a number of advantages locally in the trust and probably

the most obvious of which would have been the added capacity that the

treatment centre would bring and it was felt that this is probably going to be

very beneficial and I think everyone had realised that the PFI build that we had

got was probably going to be slightly too small for present demand and,

certainly, for our future demand.

(Site C: hospital consultant II)

It was a very similar story at Site G, where the initial motivation was not

about a TC but rather about slightly increasing the capacity of the day case

facilities. There had been a consensus within the trust that the hospital

needed a day care unit; one of the clinicians claimed to have spearheaded

this:

I was one of those consultants who, a year or two back [i.e. some three years

before the TC opened], perceived that we didn’t have a day care facility and

that a day care facility would be advantageous for all concerned and as such I

was one of the driving forces behind the call to expand in that area and I wrote

a number of notes and letters and argued the case that we should have a day

care unit.

(Site G: hospital consultant)

4.1.5 Improving staffing levels

The benefits of a TC in attracting good staff were also mentioned at a number

of our sites, either because the added work necessitated additional staff, or

because the new ways made it easier to attract good staff:



This was a way of getting extra consultant staff and extra anaesthetists. Off

the back of the [diagnosis and treatment centre] we’ve made something like –

don’t quote me the exact figure – but 10 or 12 appointments. We’ve made three

or four in urology, three or four in orthopaedics, two in general surgery and

about three or four in anaesthetics. So we got a substantial increase in staff.

(Site F : senior hospital consultant and manager)

At Site C, where there was a history of difficulties in recruiting particular

types of staff such as theatre technicians and nurses, the development of the

TC was seen as feeding into a larger process of role redesign, which could

address skill (and staff) shortages. As a briefing paper presented at a

workforce planning meeting described:

Within [the hospital] we need to think bigger to maximise the effect that role

redesign has the potential to do. The danger with singular roles is that when

that person leaves there is nobody with the skills to replace them, especially

where the role was developed with a person in mind, rather than a service

requirement supported by competency based training. To have a bigger impact

on health care we need to look at developing new roles on a larger scale,

identifying competencies required and providing access to the training

requirements to support this. We need to do this with an understanding that

these new roles may become obsolete alongside existing roles in the future.

Role redesign should create a culture which will; challenge existing ways of

thinking, where the primary focus is on the patients perspective, where we

examine existing processes and eliminate those processes or steps which add

little value, therefore enabling us to address capacity issues and skills

shortages… This could be achieved by blending some different versions of

process thinking, re-engineering, total quality management and lean thinking

and then linking these into current challenges, workforce capacity, pay

modernisation and EU working time directives. Service improvements will then

find new kinds of workers to address staff shortages through the development

of new roles and the redesign of existing roles. It will impact on processes, job

roles, facilities, patient care, financial recovery and how we look at the future

deliverers of care within the health service.

(Site C: briefing paper for workforce meeting, prepared by seconded member of SHA)

At Site D the initial plans for the TC were that it would be a nurse-led unit.

Indeed this strong emergent identity of the centre, incorporating advanced

training and good prospects for career progression for nursing staff, was used

to sell the TC to prospective staff during the initial recruitment phase and

subsequent education of 20 advanced nurse practitioners:

Yeah, I think the big thing for me… (a) was it a brand new project and how often

do you get a chance to actually set something up from scratch? So that’s one

thing. But also having worked at the [neighbouring trust], resources were just

really, really bad. And the clinical nurse specialist was so frustrated because

she wanted to do so much, but her patients only just couldn’t do it, because she

didn’t have the resource. But here, at the brand new centre, it’s just a real

opportunity to be able to do so much more ... We’ve been fighting for

professional status for so long and to be able to take over what the doctors are

doing and to be at the forefront, delivering what nurses haven’t done before –

we’ve got fantastic nurses. And if you do speak to any new advanced

practitioners out here, they’ve also got the bug and they just think it’s great.

(Site D: senior manager)



4.2 Improving quantity

4.2.1 Meeting performance targets

Often the senior managers of a trust were strongly driven to open a TC

because they saw it as a way to meet the NHS performance targets that were

becoming both increasingly important and progressively more challenging for

their trusts to meet. In fact, at all the sites the need to reduce waiting times

and waiting lists was a key motivation for opening a TC – and in this regard

their views as to the role of a TC did coincide with those of the Government.

As we saw in Section 2, the TC programme was explicitly aimed at not only

modernising care but reducing waiting times and thereby increasing access to

care, which had been a major manifesto pledge.

We will make sure that we improve the patient experience in hospitals. The

patient experience here is actually very good. What we need to do is make sure

we deliver on some of the time issues as well for them and manage the waiting

lists effectively.


Often the trusts saw the potential for the new TC to reduce waiting lists as

being principally about increasing capacity – bed numbers – so as to increase

throughput:

We have a real problem in terms of capacity, long waiting lists, we only had

four theatres. We were expanding in terms of orthopaedics but the orthopaedic

surgeons couldn’t get the patients in because we didn’t have the capacity in

terms of theatres and beds. And even though we had a large elderly population

we were very poor in terms of the proportion done as day cases. I had a strong

feeling that the reason why we had a low percentage of day cases was because

of the ageing population. I also felt that once we had a dedicated day case unit

they could get some of those patients in as inpatients, that change would

happen, which in fact it did.

(Site G: senior manager )

The treatment centre, for us, is not a build that just increases our elective

capacity. What it does is increase our overall capacity.


There was also a sense that increased capacity could also help other trusts

meet their waiting list targets – hence the intention of several of our sites to

take on some of the elective work of neighbouring trusts, known to be having

difficulties meeting these targets (see next section).

The TC could also help meet other targets. At Site B for example, the really

urgent performance problem was to reduce the unacceptable wait that

patients were having in the emergency department. This had become a real

concern for the hospital, and it was a consequence of there being insufficient

beds on the wards for emergency department patients to be admitted to. And

the shortage of inpatient beds was partly due to inefficient planning of

admissions and discharges of elective patients, who in turn were being

shuffled around the wards to try and make space for emergency patients. A

related problem was of course that elective patients would all too often be

cancelled because there was no bed into which they could be admitted. The

opening of a TC was an unmissable opportunity that allowed the hospital not

only to manage the elective patients more efficiently, but also provide short



term space in which to move patients when they did not need emergency

care.

Site F was also motivated by the need to hit performance targets. As a major

teaching hospital it was embarrassed to be seen as failing on many of its key

targets. Some of the senior team felt that the TC, by increasing capacity and

patient flows, would help alleviate those problems. But as will be described

below, this was but one motivator among several, and coincided with the

desire to improve efficiency, attract more patients (and the income that

flowed with them) and remain politically ahead of the competition.

4.2.2 Improving provision of services across the locality

There was no doubt that the desirability of a TC was often increased when it

was linked to meeting the need for increased capacity across the whole of the

local health economy in order to improve access to services.

What the PCTs needed [was] to plan collectively to deliver the NHS Plan in

December 2005, and it was clear there was a shortfall in capacity. Particularly

[Site C] had identified a shortfall because of growing population, the need to

clear backlogs of waiting lists and so on, as per other health communities. And

because [Site C], the new [hospital] wasn’t actually open… for another couple of

months, this idea of building a treatment centre on the [Site C] site was mooted.

And then of course all the interim debates started about what should go in it,

what kind of services should it provide, and I think [the local] PCT from the

outset was clear that it needed to augment the existing elective capacity for the

population.

(Site C: local PCT senior manager)

What became very clear... was that there was a significant orthopaedic gap in

the health community that the ..main provider just was not going to be able to

fill. We looked at various options for delivering and additional activity, some

[approximately 700] cases for that year. One was to run waiting list initiatives

at that hospital, another was to purchase a mobile theatre [there] and try to

bring in locums. We looked further afield at that time. There wasn’t really

anywhere else that had [the necessary] capacity. We could have farmed it out

in various sort of rather piecemeal ways, but there was no real one solution,

and then [Site G] came forward and said actually this day case unit that’s not

being fully utilised, we might be able to do something [with the capacity there].

(Site G: PCT manager)

We were quite keen on the idea of getting our own waiting lists down, firstly

because we had our own problems with targets and here we were being given

all this extra capacity, and the second thing being that there was a general

feeling that if you got your waiting lists down then you could then attract

patients to come here simply because they wouldn’t have to wait so long to be

seen because we got the waiting lists down.

(Site F: senior hospital consultant/manager)

What is less clear, however, is the extent to which the estimates of population

need and the likely demand for the new TC were thoroughly analysed and

thought through. Indeed in retrospect it seems that they rarely if ever were.

Site A, for example, was partly designed to solve a pressing waiting list

problem for a major teaching hospital but it was also intended to reconfigure

the services for that particular specialty across the locality, providing a

specialist service across several trusts for patients with low co-morbidity.



The board had started to think through a different model of offering particularly

surgical activity, in terms of the separating out. At the time, very much the

thinking was, you know, the high volume, low cost sort of stuff. And so that

was the initial idea – that here’s this hospital, we have pressure, in terms of our

elective capacity, wouldn’t it be a good idea if we went down the line of the

American sort of surgicenter? So I think that was the thinking. … So I think it

was the coming together of an opportunity – the building was free – pressure on

the existing hospital trust, in terms of capacity and some doctors out there

started to think differently about how they could work. And I think probably the

product… the result of all of those three things coming together was the

acquisition of [Site A].


The intention was to bring in large numbers of patients through the Patient

Choice scheme, but in fact within a year – by which time the numbers of beds

had been increased fourfold – the flow of patients was only half what had

been anticipated. This setback could partly be explained, some of our

respondents told us, because the planning assumptions about the type of

case mix that the TC would attract had been completely wrong.

[The planning by the host trust] wasn’t very sophisticated but then the time

frame was such that there wasn’t sufficient time in the process to do that in

terms of working it out and there were a couple of mistakes made. The main

mistake that was made was an assessment made of the lists which was

inaccurate in that 70 per cent of the cases would be minor… 30 per cent would

be [major]. In fact it turned out nearly to be the reverse.

(Site A: senior hospital manager)

A lot of [Site A’s] early problems were [that] they weren’t geared up to deal with

common co-morbidities.

(Site A: SHA manager)

Such inaccurate forecasting of the likely patient flows was not unusual, partly

because of the haste required in putting together the bids to open a TC within

the timescale of the TC programme, partly because of the lack of good

epidemiological information and analytic skills, and partly because some of

the planning teams were so enthusiastic to get the new facility and develop

the new ways of delivering care that they turned a blind eye to the lack of

supporting evidence about the viability of the likely patient flows and

casemix. Major decisions seemed sometimes to rest on an almost cursory

estimate of need:

We then investigated what we might reasonably do here and decided partly

because of the way the services were organised here and partly because it

married up with the waiting lists as published around London on the net that

we would do [three specialties]. So that was the mix of where the biggest

waiting lists were by specialty, and it suited us with the big [departments we

had in those specialties]. And so it worked out roughly about right.

(Site F: senior hospital consultant and manager)

In fact as things panned out, it wasn’t remotely right: just over two years

after it had opened the TC was forced to close through lack of patients.

Many single specialty and teaching hospital TCs were later accused of ‘cherry

picking’ cases and thereby affecting neighbouring trusts by leaving them with

the more complex patients. Site D was designed from the beginning to avoid

this and provide a sector-wide service. All the local organisations (trusts and

PCTs) that were involved in setting it up shared the same problem that



inpatient waiting lists in that specialty were their main obstacle to achieving

the access targets in line with the NHS Plan. At the time (circa 2000) there

were not enough beds, theatre lists or surgeons to do all the work required.

Indeed the possibility of a centre to tackle that problem had been under

discussion over five years earlier.

It started really out of a couple of discussions that were held at the acute chief

executives’ forum at the strategic health authority. This is an informal meeting

of chief executives of acute trusts... It meets on a quarterly basis, and I used to

attend as a token representative of PCTs… And the NHS at the time was going

through some changes. The main changes it was going through was an

acceleration of activity, people were starting to talk about the acceleration of

activity associated with increasing the through-put of patients, increasing

capacity, getting the waiting lists down, etcetera, that sort of discussion. And it

was felt by a few trusts that this would be a good wheeze. It would be a good

wheeze for two reasons. It would be a good wheeze because it would actually

help with addressing the capacity issue, but it would also be a good wheeze

because it could prove to be a method of extracting resource from primary care

trusts, because it would have high political patronage, it would be in a position

whereby it wouldn’t be allowed to fail… Hence, there was logic in doing it,

whatever the rationale for the acute chief executives was. And for this reason, a

[...] steering group was set up of which I was a member… and the thing just

galloped away in the distance, and we’re left with what we have today, which

is a treatment centre.

(Site D: senior clinical manager, PCT)

The original aspiration behind this partnership model was to transfer all

elective patients in that specialty to the TC at Site D and thereby release

capacity for over 3000 general surgery operations at the base hospitals. This,

it was claimed in the publicity about the TC, would reduce waiting time to

meet NHS Plan targets; give better value for money than development of

additional capacity at the host trusts; improve access; and, not least by

separating off the elective theatre sessions, release bed and theatre capacity

at ‘base’ hospitals to pursue NHS Plan targets for general surgery.

The proposal for separating elective and emergency care at Site H originally

came out of a major review of service provision some five years earlier, and

subsequent deliberations, which had included a review of capital investments

across the local trusts and PCTs. This process, coupled with an inspirational

visit to the Ambulatory Care and Diagnostic Centre, led to the realisation that

there was now – with the TC programme – an opportunity to meet the notion

of separating emergency and elective care and to improve capacity as set out

in the NHS Plan. So despite the host trust’s initial reluctance to have any

explicit separation of planned and unplanned care across the two sites, the

eventual reorganisation of the trust that included the new TC at Site H took

due note of the need for appropriate provision across the sector. From then

on, many of the key local actors saw the development of the TC as being

driven mainly by this strategic reconfiguration – and consequent relocation –

of services across the locality.



4.3 Improving kudos

4.3.1 Improving the profile of the organisation

At Site F the primary motive for a TC was always more a matter of increasing

efficiency/ productivity than qualitatively improving the patient experience.

Although Site F did have its share of influential modernising idealists, the

resultant direction was – as always – shaped by the ongoing interaction of a

number of differing views. Dominant was the desire to remain politically

ahead of the game and achieve the levels of performance required by the

government:

I would have thought there is a political drive from this trust to be at the

forefront of all things new, wonderful and modern and therefore this was a new

and wonderful modern thing and it was right for us to have it.

(Site F: senior hospital consultant/manager)

Question one, was it really set up initially to encourage new ways of working or

was it set up because, (a) maybe it was a political favourite at the time and (b)

because we thought we’d probably earn a bit of money on the back of doing

loads of other people’s work? Answer is probably that, not the innovation.


Thus both the political incentive and the increased throughput coincided with

the strong drive to achieve more income through the increased activity that a

TC would bring. The need to increase activity overwhelmed even the most

modest attempts to modernise the care pathways, a point that may have

been disguised among the rhetoric of change, as this jaded champion of the

modernisation agenda wryly remarked:

If you were to have this conversation with any of the ‘management’ guys, they’ll

tell you the right gobbledygook, and tell you that we’re absolutely committed to

that [modernisation]. In reality, we’re so struggling to get the work and get

through it and stay afloat financially, that that’s not the agenda as I perceive it.

There are people beavering away to create that perception, and there are things

like pre-admission where it has been the sort of model… And there are the

other things… for example patients arriving on the day of surgery rather than

the day before for surgery. Those things have all been discussed as part of

developing things through the treatment centre and then on to elsewhere. But it

hasn’t. I don’t think that’s been as significant as it was at the outset but it really

was one of the main driving forces in justifying it and negotiating it because the

process of actually getting the work and doing it has been so difficult. We’ve

been crawling in mud… It seems to me that the perception is, if you paint it as a

modernising thing that’s good, therefore that’s what will be done.

(Site F: senior hospital consultant and manager)

In short, the main motives at this high profile trust seemed to be a

combination of a felt need to remain in the ‘good books’ of the Department of

Health, the Government and the media – for example by getting waiting lists

down and being seen to be engaging in the spirit of the modernisation effort –

at the same time increasing activity and income so as to survive financially.

Several sites that were less overtly entrepreneurial, such as Sites C, E and G,

also saw the potential for bringing in elective work from beyond their

immediate area and thus boost the financial state and the reputation of their

trust.



It was felt as well that it would helpful in terms of bringing in outside work and

to also bring in funding and would improve the whole strength of the services

that we were providing in elective surgery.


This void in our new building could very easily and quickly be converted into a

state of the art day case unit. We wanted part of that for our own work but

there was obviously a vacancy there [for outside work] and that’s what we did..

(Site G: hospital consultant/manager)

Site E was in little doubt as to the benefits that would accrue from opening a

TC following the political furore over the earlier hospital closure at that site.

The chance of attracting patients from afar, while a nice bonus, was a side

issue. Several interviewees at the start of the research suggested that the TC

was a way of regenerating the hospital site and its reputation by drawing

more elective surgery back to the town (the unit already had a day surgery

suite):

We’re putting [Site E] on the map, really, for treatment centre work... and with

the treatment centre hopefully lifting the profile of [Site E] and what’s here, it

might settle down and sort itself out.

(Site E: nurse manager)

We’re starting to say to them, we’re going to shine, you always have done but

now the spotlight is on, so carry on doing what you’re doing in the way you’ve

done it and the excellent service you provide, but now people are going to

notice.

(Site E: Nurse manager)

However there were some fears that the local community saw the TC as a

replacement hospital and not a TC.

The closure of the hospital is in the background the whole time when you’re

looking at the treatment centre and it’s one of the reasons why I’m very keen

that we stop calling it a hospital. It’s an interesting debate because at the

moment if you look at the road signs they all say ‘[Site E] hospital.’ They don’t

say ‘treatment centre’ and we are going to change that... They need to say

‘treatment centre’ or ‘minor injury unit’ because that’s what it is but it isn’t a

hospital anymore.

(Site E: clinician manager)

Six months later, all road signs read ‘Treatment Centre’. However, during a

round of final interviews two years later, a new senior manager confirmed

some of the earlier interviewees’ views:

I think it was wrapped up in the politics of the area – the downgrading of the

hospital – I think there was an opportunity there that was taken which was

based on politically astute reasoning. But activity was still happening on this

site so you weren’t looking at putting something completely new in; you were

looking at a rebuild…. I think the rest of the trust thought that it was a way of

extending the hospital and it wasn’t a treatment centre in the true sense of the

word… [The local people] wanted a hospital back and this was as close at they

could get. The local MP still argues (for) flashing blue lights back on this site.


Finally, sometimes the motivation was simply to try to be among the best.

For example, fieldnotes from a discussion with a senior consultant/manager

at Site C report him saying: ‘[The] originators wanted a wonderful TC and for



[Site C] to be seen as good in the TC world.’ This view was also apparent at

Site G:

We wanted to use all the ideas that were being put forward, we wanted to think

of anything that would hold [Site G] up as being a good example for everything.

I wanted people to enjoy working there, I wanted consultants from other trusts

to want to come back and I wanted patients more than anything to say that was

a fabulous experience.

(Site G: senior nurse manager)

4.3.2 Realising personal ambition or vision

It was not always easy to distinguish individual enthusiasm motivated by an

idealistic vision from that which was due more to corporate loyalty (wanting

one’s trust to be the best) or even to personal ambition. However it was

possible to perceive all of these drivers playing their part as we heard about

people’s views and involvements in pushing for the establishment of a TC. At

Site E, for example, much of the success was widely attributed to the project

manager who was brought in as a champion of the TC concept, bringing with

him experience and a clear vision to a project that until then had been fired

mainly by the pragmatic and opportunist desire to replace lost local hospital

services (see Section 3.1). Adding his idealist view that ‘the ethos of the TC is

not around the building, it is around care delivery’ emphasised the idea that

the TC was about innovative approaches to the delivery of care, of improving

local health, and of supporting the health economy by offering increased and

more efficient and effective capacity not only locally but further afield. His

success in realising that vision made the TC a showcase for the programme as

a whole as well as for the local SHA and region. This allowed the TC to be

treated as almost a separate independent organisation, which fulfilled the

ambitions of its senior managers and allowed them the freedom to develop

the centre more or less as they wished, to establish links with a wider

commissioning network and to make deals with the private sector treatment

centres, and so on: in short to operate the TC almost as a hospital in its own

right. But at the same time it also gave the individual who had been at the

centre of it all the opportunity to move on to a senior position in the private

sector.

Our sample sites included examples of ‘turf battles’ where as is so often the

case, it is difficult to distinguish whether the victories and defeats – which did

so much to shape the configuration of the TCs – were personal, ideological or

professional. In the following example, the fundamental question of

separating elective from emergency services seems to have been at stake,

but paradoxically this is seen as being at odds with the shift in ideology of

‘modernised’ care provision, and bound up in the speaker’s mind with the

reallocation of personal power:

Anyway, so at this time out, [M] presented a version of what I had produced but

it wasn’t the same and it wasn’t as good, I didn’t think, and [K] presented his

concept of planned and unplanned, which of course is not unheard of and has

been established in other places. Essentially the group were asked which they

preferred and they went for the planned unplanned model. So then [M] went

away and worked out and divvied up all the jobs and of course that didn’t

really leave my job in there anywhere. So basically there was a structure that

was a management structure, planned/unplanned with all the other bits like

facilities and what have you still there, no director of modernisation, in fact no



modernisation anywhere in sight, which as I said, that was something that

really troubles me, and the treatment centre was obviously part of [K’s] empire.

(Manager)

Sometimes wider political forces dictated a particular approach to thinking

about the TC in the local context. For example at Site C the arguments over

the private finance intiative that lingered on from the recent new hospital

build (and followed though the TC build) resulted in the management team

having to respond to pressure both from central government and the trade

unions. They felt strongly the constraint of being between a rock and hard

place: the government was pressing for a success story in time for the

election, while the unions were using the TC as a stick with which to beat the

private finance initiative.

4.4 Summary

As this section has shown, the local organisations that took up the challenge

of establishing a TC did so for a wide variety of reasons. The motivations to

open a TC were, as we have suggested, often rooted in local history and

context (for example the ‘need’ for a day care unit, finding a use for a

recently-acquired former private hospital and so on) and to some extent

these factors were unique to each site. However there are common features.

Firstly, the people. There is a strong sense that the decision to open a TC was

dependent on the resolution of a number of often conflicting views (which we

have referred to as contests of meaning) between different individuals or

groups within organisations. It is clear that while initially there was a strong

role for opportunists in getting the idea off the ground, in the subsequent

stages the particular ‘version’ of a TC taken up by the organisation was

developed out of the ongoing struggles between opportunists, idealists,

pragmatists and sceptics.

A second, unifying thread to be found in the varied reasons why these sites

developed TCs is the sense that they wanted to improve – to ‘improve quality’

to ‘improve quantity’ and/or to ‘improve kudos’. In improving quality some

sites prioritised patient- focused approaches to care or ‘modernising’ patient

processes. This included such things as the fundamental reform of traditional

clinical practices and transformations in skill-mix. In improving quantity the

case studies were hoping to increase capacity, throughput and activity, and in

this they were tightly coupled to an agenda set down by the Department of

Health, which (Section 2) was concerned with reducing waiting times and

increasing activity. In improving kudos for the organisation the sites were

hoping their TC would make the organisation more competitive (or at the very

least to prevent them falling behind and becoming uncompetitive). Some

sites also used ties with external stakeholders (SHAs or higher up the

Modernisation Agency or Department of Health) to improve the profile of the

wider trust (or key personnel within it). This is evidenced in the swift

departure of several of the enthusiasts (often also ‘opportunists’, also in their

career paths) once the TC was secured.

The decision to apply for TC funding inevitably resulted from contests of

meaning, and as described in Section 3, these were clearly influenced by key


external milieus. For example there may have been – and usually were –



idealists who saw the TC as a chance to improve patient care. But there were

nearly always sceptics who saw it as yet another fad, opportunists who

wanted to grab the funding to develop a new service that was in any case

much needed, and pragmatists who wanted to do whatever seemed most

likely to improve the service with minimum fuss. Even where there was

consensus among those with the power to make the final decision, there were

always discrepancies about their underlying motivations, rationales and

intended outcomes.

Most of our sample sites had key actors who were motivated by one or more

of the above rationales for opening a TC. Our interview data reflected

disparate views and biases: for example whether interviewees told us that the

main motive had been principally to improve quality of care or to improve the

achievement of performance targets would depend upon which side of the

arguments they had been on. But it was possible to discern from the many

sources what the balance had been between the various viewpoints and how

the decision to go ahead with the TC had come about – not least because

many interviewees recognised that there had been a range of views. It would

be a mistake, therefore, to suggest that the organisation was motivated by a

given factor to set up a TC: rather there would be a certain configuration of

views that led to an evolving and constantly negotiated clusters of decisions

that gradually emerged as something (at least) approaching some of their

initial visions of a TC.



Section 5 Environment and influence: the wider policy context surrounding treatment centres

5.1 The policy context since 1997

The origins and history of TCs have already been described in detail in

Section 2 of this report. To summarise, the official start of the current TC

initiative was a Government White Paper The NHS Plan (Department of

Health, 2000a) which promised ‘a radical new kind of service’ (Department of

Health, 2001). The dominant policy context for TCs was the ‘war on waiting

lists’, the main enemy being perceived as insufficient capacity within the

system. Harrison and Appleby (2005) suggest that the policies the

Government has adopted in its ‘war on waiting’ have fallen into three phases

since 1997. Together these phases set the overall policy context for TCs

during our period of research:

Phase 1 (1997-2000): during this phase the Government focused on reducing

the number of people waiting rather than reducing the time of waiting

Phase 2 (2000-2004): increased investment and targets accompanied by a

wide range of policies to help transform the way that elective care is

provided. The government introduced a number of ideas and programmes

aimed at increasing supply within the health service, including:

• treatment centres

• day surgery

• the NHS Modernisation Agency

• specialty programmes (for example orthopaedics and ophthalmology)

• patient choice.

The Government also:

• supported the development of new services in community settings

• set targets for increasing the overall number of hospital beds

• introduced a star-rating system to provide a measure of trusts’ overall

performance (five out of nine ‘key targets’ were related to waiting).

Phase 3 (2005-2008 and beyond): in 2004 the government announced a new

target for the NHS, that by 2008 no one should wait longer than 18 weeks

from referral by a GP to hospital treatment. The target was to be helped by:

• extra capacity in the independent sector, which was beginning to become

available and was set to increase

• the Government agreeing, in early 2005, to £3bn worth of contracts with

the independent sector to overcome shortfalls in diagnostic capacity.

At the same time as helping cut waiting times, TCs (both in the NHS and in

the independent sector) are intended to support other parallel initiatives such

as improving patient access and choice, and the electronic booking of

appointments and operations. Harrison and Appleby suggest that:



If all the policies in place by the middle of 2005 work in line with government

expectations, the NHS elective care system will shortly be transformed from the

‘command economy’ of the first two phases into a quasi-market economy.

Hospital trusts will be put under unprecedented pressure from patients

exercising choice (and taking the finance for their treatment elsewhere), other

trusts offering quicker access and the private sector potentially removing

business out of the NHS altogether.

(2005; p.xv)’

Beyond this, the development of TCs is also linked with wider moves to

reconfigure acute treatment services through shortening hospital stay,

‘downsizing’ hospitals, redrawing boundaries between primary and secondary

care, and re-engineering delivery processes.

As discussed in Section 2, TCs were designated one of the main vehicles for

implementing the challenging reform programme sought by the government

in the NHS Plan. Significantly for our case study sites this programme

included opening up the health care market to the independent sector in the

interest of expanding patient choice (and thereby ‘contestability’ – otherwise

known as competition). Section 6 will explore the specific impact these

various policy developments had in our eight case study sites and how our

sites responded to the resulting challenges. Here, we seek to summarise the

wider policy context in which the eight TCs we have been studying have been

operating.

The remainder of this section describes in general terms the significant policy

documents and key events which have impacted on TCs during the period of

our research and then provides an overview of three of the most influential

national policy initiatives that have been shaping the ongoing development of

TCs in the NHS, namely independent sector TCs, Patient Choice and Payment

by Results. We then report on the formation and functioning of NHS Elect – in

part a response to these drivers – before concluding with a discussion of the

wider policy context and how it has impacted in general terms on TCs.

5.1.1 Policy documents and key events

During the period under study the Department of Health provided a broad

strategy for the NHS through several major policy documents. It then set

national performance targets and introduced initiatives to help meet those

targets. We briefly summarise these documents below.

In April 2002, the publication of Shifting the Balance of Power (Department of

Health, 2002c) confirmed the abolition of health authorities and regional

offices, and the creation of PCTs. At the same time, 28 new SHAs replaced

the former health authorities and took on a strategic role in improving local

health services. Immediately after their establishment the Department of

Health asked all SHAs to identify any anticipated gaps in their capacity

needed to meet the 2005 waiting time targets. Harrison and Appleby (2005)

report that SHAs were asked to provide both estimates of what the NHS could

realistically do and their expected purchase of care from the private sector,

including overseas sources, and that this was the first time such an exercise

had been attempted across the NHS as a whole. In the same month

Delivering the NHS Plan: Next steps on investment, next steps on reform

(Department of Health, 2002b) referred directly to TCs as ‘fast-track surgery



centres’and also stated that up to 150,000 operations might be purchased

from the independent sector.

In October of the same year, Reforming NHS Financial Flows: Introducing

Payment by Results (Department of Health, 2002a) laid out changes to how

money moved round the NHS, and set up incentives for hospitals to behave

more like businesses (see Section 5.4). Then, in December 2002 Growing

Capacity: Independent sector diagnosis and treatment centres was also

published (Department of Health, 2002d) providing the ‘background and

plans for diagnosis and treatment centres and highlights the role of the

independent sector in the diagnosis and treatment centre programme’. This

signalled the beginning of the first wave independent sector TC procurement

exercise discussed in the following section. In October 2003, the word

‘diagnosis’ was dropped from the term ‘diagnosis and treatment centres’ and

both NHS and independent sector treatment centres were referred to just as

‘treatment centres’ (TCs). According to the Department of Health (2003b),

the change coincided with a significant new phase of development, providing

‘a simpler name for the public and for patients’ at a key time. It did not

ostensibly reflect ‘any change in the core characteristics of schemes, or the

overall objectives of the programme’.

In January 2005, the Department of Health published Treatment Centres:

Delivering faster, quality care and choice for NHS patients (Department of

Health, 2005c). This update on progress with the TC programme explicitly

tied TCs in to delivering the new target announced in the NHS Improvement

Plan (Department of Health, 2004c) – the follow up to The NHS Plan

(Department of Health, 2000a) – of ensuring that by 2008 NHS patients wait

no longer than 18 weeks from GP referral to treatment. This report also

announced that the Department of Health was proposing to establish five

‘centres of innovation and training in short-stay elective care’.

5.2 Independent sector treatment centres

An important part of the TC initiative has been the contracting of independent

sector companies to provide services for the NHS, including employing clinical

staff. In 2006 the Department of Health’s commercial director outlined the

three principal objectives of the independent sector TC programme

(Department of Health, 2006a), namely to increase the capacity available to

treat NHS patients, to offer patients a choice over where they are treated and

to stimulate innovation in the provision of health care. Independent sector

TCs are, however just one part of a wider concordat with the independent

sector, first announced in the NHS Plan and published a few months later as

For the Benefit of Patients (Department of Health, 2000b). Then, in December

2002, the Department of Health published guidance for independent sector

TCs and the first wave was launched comprising a planned 177,000

procedures per annum over five years at a cost of £350m per annum (total

cost £1.737bn). This first wave procurement was focused on cataracts,

orthopaedics and day case work. In the same month the first public-private

partnership TC began treating patients at Redhill, Surrey. In much the same

way that the Central Middlesex Hospital’s Ambulatory Care and Diagnostic

Centre predated the advent of NHS-run TCs (see Section 2), this centre

predated the national procurement of independent sector TCs.



5.2.1 First wave procurement: 2003

In May 2003, the Government announced that 250,000 finished consultant

episodes (FCEs) – just under eight per cent of the total activity in the NHS –

would take place in the independent sector by the end of 2005. On this scale,

this first wave of independent sector TC procurement appeared to pose little

threat to NHS services, and this was reflected by rhetoric that presented

independent sector TCs as a ‘pragmatic response that did not threaten the

NHS’s long-term role as a provider’ (Carvel, 2005). The words of the then

Secretary of State for Health were reassuring in this regard:

Patients will continue to choose NHS hospitals for most acute care, so for the

foreseeable future NHS providers are likely to continue to deliver most health

services. However, there also needs to be a greater plurality of provision – to

expand capacity fast, to stimulate improvements.

(Reid, 2005; p.10)

In short, the NHS was declared secure, while choice, capacity, quality and

service were said to be open to significant improvement.

These first wave independent sector TCs were defended on the grounds of

offering an efficient and rapid response to NHS capacity constraints and the

perceived inability of the NHS to expand sufficiently in order for government

targets on patient access to be met within the timescales set. Also, by

drawing on overseas expertise and trained professionals (which also ensured

that these clinicians would not have conflicts of interest about their own

private practice (Stevens, 2005), ‘additionality’ of publicly-funded capacity

could be achieved as well as providing the catalyst for wider changes in what,

up until now had been perceived as a (clinically) protectionist market:

We are going through a huge process of change where we are encouraging

people within the NHS to break down artificial demarcations. That is a process

we have seen before in many other industries in order to get better value for the

patient and, at the same time, outside, as well as inside, the NHS we are using

the power of the NHS in purchasing to break what some people would

previously describe as a monopoly cartel or a closed shop caused by a tight

control of supply and an encouragement for huge demand.

(Reid, 2004)

In September 2003 the Department of Health announced preferred bidders

for the first wave independent sector TCs and the following month the first

purely independent sector TC commenced services to NHS patients.

In May 2004 the Department of Health announced two supplementary

contracts with the private sector to focus on mainly orthopaedic procedures,

which had significant implications for some of our case study sites (see

Section 6). These schemes, known as G-Supp (General Supplementary) were

intended to enable primary care practices to purchase operations from the

private sector for NHS patients. At the time of writing G-Supp has had two

phases. The value of G-Supp 2 was £54m and work was procured by the

Department of Health under its new purchasing arm, the Commercial

Directorate.

By October 2004, one fixed and two mobile independent sector TCs were fully

operational and interim services were being provided on three further sites.

At the same time, the 2003 target figure of 250,000 FCEs in the independent

sector was doubled to 500,000 (15 per cent) by 2008 by means of a second



wave of independent sector TC procurement (see below). Attitudes to

independent sector TCs began to harden. While there remained almost

universal agreement on the principle of separating elective and emergency

care (which underpins both the NHS and independent sector TC

programmes), far from wishing to enter into partnership, many staff in NHS-

run TCs including those in our own study began to show increasing hostility

towards the independent sector TCs:

More and more money is being poured into the health service… an awful lot of it

is just going down routes that are absolutely a total waste of money … I’m a

great believer in NHS treatment centres but I’m blowed if I can see why we

should be paying some entrepreneur in Dorset to turn a stately home into a

hospital, make money for himself and his investors and at the end of it all what

has the NHS got? Absolutely nothing. Probably some fairly dubious results from

the surgery and nothing left behind.

(Site F: hospital consultant)

5.2.2 Second wave procurement: 2005

In March 2005 the second phase of the independent sector TC procurement

was launched comprising both elective and diagnostic activity. Up to 250,000

elective procedures per annum over five years were to be procured plus the

creation of an ‘extended choice network’ of an additional 150,000 ad hoc

procedures per year (Department of Health, 2006). The cost was estimated at

£550m per annum (again for five years and at a total cost of £2.5bn plus

£175-200m per annum for the Patient Choice network). This procurement

also included two million additional diagnostic procedures per annum (£1bn

over five years) including boosting MRI capacity by 15 per cent and

employing more radiologists to deliver over 630,000 (non-urgent) additional

MRI scans via 12 mobile units. In addition, as Harrison and Appleby (2005;

p.45) suggest, ‘these contracts provide for massive increases in capacity –

about one-third in the case of computerised tomography scans and 60 per

cent in the case of endoscopies’.

Around this time (as evidenced by contemporary national surveys and

corroborated by our own research) many NHS staff began to see independent

sector TCs as privileged to such an extent by the Government that they now

threatened to undermine their own TCs’ long-term survival. For example, a

survey of acute trust chief executives included an assessment of the impact

that independent sector TCs were having on existing NHS services including

TCs: 77 per cent of respondents said that independent sector TCs have

implications for ‘existing elective work’ – particularly orthopaedics – and 25

per cent said they had implications for NHS-run TCs. The accompanying

survey of PCT chief executives reported that in 10 per cent of them over 50

per cent of the extra capacity purchased from the independent sector TCs was

not actually being used (Health Services Journal, 2005b). This growing feeling

of unease was further fuelled by Department of Health pronouncements to the

effect that the second wave was also about introducing ‘contestability’, that is

making NHS hospitals compete with one another and the private sector. As

one chief executive told an NHS confederation conference:

In terms of surgical centres. I don’t think we have overcapacity now and I

presume they are talking more about [the situation] when new centres come on

line... We need more capacity so we can offer choice and there is some



contestability. If everything is operating at 100 per cent that is stultifying. We

need enough dynamicism (sic) to allow for some contestability.

(Health Services Journal, 2004)

The then Secretary of State for Health’s response to those who claimed the

increasing role of the independent sector was a form of ‘privatisation by the

back door’ was to reframe the issues in the language of equality and fairness,

while reiterating government commitment to the founding principles of the

NHS:

To those who have misgivings about it, I say two things: firstly, I will protect the

founding principle of the NHS of equal access to health care provided free at the

point of need … and the second is I will never apologise for the extending to the

mass of working people the privileges that have been monopolised only by the

well-heeled and well-connected since time immemorial. Why on earth would we

not be proud of extending that degree of information and power?

(Reid, 2005b)

Nonetheless, there are indications that the increasing role of the private

sector in TCs exemplifies a more general redrawing of the boundaries

between public and private sector that is a (controversial) part of current

government policy. For example, in south-west Oxfordshire the PCT was

refused the right to withdraw from a cataract surgery contract with an

independent sector TC when the PCT realised damage might be done to the

viability of the NHS’s Oxford eye hospital (Carvel, 2005). The volume

guarantees given to the independent sector TC in Oxfordshire – indeed all

independent sector TCs – seem to conflict with the Choose and Book policy

(see Section 5.3) being rolled out across the NHS. As the Health Services

Journal put it:

[Independent sector] TCs will be made artificially busy either simply by

channelling any growth towards the private sector or because of the failure of

NHS organisations operating under a more onerous financial regime. In either

case, this is hardly the pluralistic market championed by the government in

which patients shape provision by choosing on the basis of quality and

timeliness of care.

(Health Services Journal, 2005)

A second anecdotal example comes from Trent and South Yorkshire where

GPs from 28 PCTs were encouraged to make more use of the local

independent sector TC for orthopaedic surgery run by South African Care UK

Afrox Healthcare (which had a £98m five-year contract for more than 5000

operations). However, take up was reportedly slow as patients continued to

opt to go to the large NHS hospitals in Nottingham partly (a) because their

GPs knew the consultants there, and (b) the NHS hospitals were easier to

reach by public transport. Newspaper reports (see for example Revill and

Hinsliff, 2005) suggested that this lack of take up of independent sector TC

capacity had cost the local PCTs £2.3m in the previous year (equivalent to

400 hip and knee replacements) .

The BMA suggested that independent sector TCs were detrimental to local

health services, accusing the centres of depriving hospitals of resources and

patients. In a BMA survey of NHS clinical directors, 68 per cent of

respondents had said that independent sector TCs had had a negative effect

on the facilities provided by their trust (BMA, 2006b). One example cited was

of Southampton University Hospitals NHS Trust closing an orthopaedic ward



because it claimed that much of its work had been taken over by Capio, a

Swedish-owned company based in Salisbury.

Our own research revealed similar perceptions that, directly or indirectly,

financial damage was being done to the NHS, and not just by the independent

sector TC programme. For example, a senior manager from a health economy

that contained one of our case sites described the effects of top-slicing PCT

budgets to fund a TC in the NHS:

It has drained I would say approaching £100m from the sector, and I’m a chief

exec of a PCT with a significant financial deficit. It’s a great shame, all this,

because certainly having an elective orthopaedic hospital could radically

change things for the better in orthopaedics, both for the patients, for the staff,

training – everything. So I think it’s a real missed opportunity. I don’t know

whose decision it was. If it was a politician’s decision, it’s almost forgivable. If it

was a senior manager’s decision, it’s outrageous because it has cost this sector

£100m.

(PCT senior manager)

All these examples offer somewhat different perspectives on the

government’s commitment to what Currie and Brown (2003; cited in Hoque et

al, 2004) have termed the introduction of a system of ‘entrepreneurial

governance’ So, from professional magazines like the Health Services Journal

– which devoted the first five pages of one edition to the topic – to

widespread coverage in the national press, and onto professional bodies such

as the BMA – with its warning of the imminent destabilisation of NHS hospital

economies – it is clear that independent sector TCs have stirred up an ants’

nest of issues for debate. Indeed, commentators have suggested that ‘no

other issue among the avalanche of reform which has hit the NHS in the last

five years has caused such consternation among senior health service

managers’. (Health Services Journal, 2005; p.3).

On the other hand, advocates of independent sector TCs and Patient Choice

(see Section 5.3) have fought just as hard for their corner, arguing that

independent sector TCs will raise standards and improve both access and

choice for patients. Contrary to the examples described above, proponents of

the independent sector TC programme argue that patient satisfaction is

running at over 94 per cent, that value for money has been achieved by using

bulk buying to reduce what the NHS used to spend per case on independent

sector activity and that clinical quality is driven upwards through high

standards and key performance indicators (Department of Health, 2006a). A

new body representing 11 independent health care organisations working

with the NHS has been established, in part – reportedly – to combat the bad

publicity over plans to expand the network of independent sector TCs (British

Medical Journal, 2006).

Nonetheless, as revealed in our research there are inherent and inevitable

tensions between the strategy of devolved power as evidenced by foundation

trusts and practice-based commissioning, and the top-down implementation

that seems to surround independent sector TC procurement, and even to a

lesser extent the development of NHS-run TCs. This is discussed further in

Pope and Robert et al (2006).

Some in the TC study sites were bitter, believing that the Government had

become the masters and they the victims of double-talk while others simply

accepted this the way the NHS has always been run. At the very least there



was confusion about the different versions of reality being presented.

Politicians took the view that capacity levels in the NHS were ‘about right’,

that any extra capacity that existed in TCs was a relatively small proportion of

overall NHS activity. For example, the Health Secretary told a House of

Commons select committee that:

The level of spare capacity in the NHS in England, for which I am responsible,

is… about nine thousand places, I think. That is out of seven million treatments

a year. Let us put it in perspective. That is out of seven million treatments in

and out of the secondary sector of the NHS.

(Reid, 2004)

Some practitioners working in our TC study sites vehemently disagreed,

claiming that ‘patients are not coming’, that their TCs were ‘running on

empty’, a problem that, not surprisingly, was said to have worsened since the

opening up of the market to independent sector TCs:

Here we are, we’ve got six theatres, we’ve got five wards, three have been

completely revamped, we've got this fabulous staff, we’ve got all these amazing

facilities, and we’ve only got 20 patients in the building... [The Government]

insist on pursuing this independent sector nonsense, and I think that’s what we

find so frustrating. I think from the Government’s point of view, they just say,

we've just got to increase the capacity, we’ve made this commitment to an

independent sector, 15 per cent or 20 per cent, or whatever, and everyone’s

work has got to go through the independent sector, and that’s the promise we’ve

made. Well, that’s fine, but then you are going to lose some NHS treatment

centres as a result, so they’ve got to decide somehow, how that’s going to work,

because you’re not going to be able to have it every way.

(Senior manager)

In January 2006 it was reported that 21 independent sector TC schemes were

open and a further 11 were to open over the next 18 months, and that over

250,000 patients had been either treated or received a diagnostic service

from the independent sector (Department of Health, 2006a). In 2006 it was

expected that independent sector TCs would treat a further 145,000 NHS

patients; despite this seemingly rapid expansion in independent sector

activity when fully rolled out independent sector TCs will account for less than

one per cent of the total NHS budget and only about 10 per cent of all

elective procedures. Independent sector TCs are said to ‘exist to challenge the

system and supply some additional capacity but they do not represent an end

to the NHS as we know it’ (Department of Health, ibid).

But then – just as this report was being completed in May 2006 – a decision

to cancel seven of the 24 planned local independent sector TCs (representing

some £550m of work per annum) was announced. The remaining 17 schemes

were delayed for up to a year. The reasons behind this sharp about-turn in

policy are discussed in Section 10.

5.3 Patient Choice

By the end of 2005, all NHS patients were to be offered a choice of four or

five alternative providers at the point of referral (that is, in the GP surgery),

which would include independent sector providers. NHS patients were to be

given wider choice by their GPs of where, when and how they are treated:



The New Labour Government is creating a decentralised, personalised, and

publicly funded NHS, committed to patient preference and the extension of

choice ... We are promoting diverse forms of public ownership, public provision

and public management … We are empowering patients to play a bigger role in

choosing where and who provides them with their health service.

(Reid, 2005a)

As Harrison and Appleby (2005; p.29) state, there is little doubt that the

initial reason for introducing choice was to achieve a reduction in the number

of people waiting for six months or more. ‘Choice’ was introduced as a pilot

scheme for heart patients in 2002 and then the London Patient Choice Project

offered patients the chance of quicker treatment in areas such as

orthopaedics, and ear, nose and throat surgery. The project began with

cataract surgery in 2002 and was then extended in 2003 to cover other

specialties and was also piloted in other parts of England. (It is worth noting

that findings from an evaluation of the project suggest that although choice of

provider was popular among those waiting for elective treatment, patients

were less likely to opt for quicker treatment by an alternative provider if they

were older, if they had low education levels, if they had family commitments

and if their income was less than £10,000 per annum (Burge et al, 2005).

However, such a scenario is likely to be highly condition-specific. In the

coronary heart disease scheme, 50 per cent of patients who had been on the

waiting list for six months or more took up the option of going to an

alternative hospital to avoid a longer wait (Le Maistre et al, 2003).)

While the current emphasis on ‘choice’ is concerned with the emerging

models of organisation and management for the public services – also

described in somewhat dramatic terms by the then Secretary of State for

Health as ‘the crucible in which the future shape of the progressive centre-left

politics is being forged’ (Reid, 2005a; p.2) – support for Patient Choice was

neither unconditional nor universal (Bate and Robert, 2005). A report by the

National Audit Office found that the roll-out of ‘e-booking’, which allows

immediate electronic booking of patients' choices, was slow: only 63 bookings

had been made by the end of 2004 out of a workload that will eventually

involve millions of bookings.

Other systemic problems have also been put forward as reasons for the

‘stickiness’, whereby patient choice remains more concept than reality, and

patients are not moving around the system as freely and easily as advocates

of the market would want or have expected. For example, according to a

recent national study, top-down implementation and poor strategic planning

would appear to have led to many TCs being built in the wrong places:

New capacity (or measures to use existing capacity better) needs to be focused

on the areas surrounding London, on East Anglia, and on Devon and Cornwall.

These are not the areas in which diagnostic and treatment centres are to be

located, thus given the current patterns for referral and capacity these facilities

may do little to increase choice.

(Damiani et al, 2005)

As one of our interviewees put it:

There’s no point in putting a fantastic supermarket on the Isle of Skye and set it

up to service a million people if you can’t get the customers to it.. You’ve got to

get the customers to the people who are delivering provision.

(Senior manager)



Then there are problems or shortcomings within the systems themselves, for

example a number of our respondents described how they had failed to

anticipate the practical difficulties they would encounter in moving patients

between providers, because adequate information, financial and clinical

systems did not exist, or had never been designed with this in mind. Poor

financial and administrative mechanisms for facilitating the movement of

patients around the system contribute further to the ‘stickiness’ mentioned

above; administrative blockages or planning inadequacies prevent or slow

down the ‘transfer’ of patients between providers.

5.4 Payment by Results

To enable patient choice to apply nationally, the Department of Health

introduced a new system known as Payment by Results, which aimed to

directly link a hospital’s income to the amount of work it performed (Harrison

and Appleby, 2005). This new system was partially introduced in April 2003.

Tariffs (based on health care resource groups) were initially applied to non-

emergency surgery for 15 procedures, including cataracts and hips, both

areas where there were significant waiting lists, and both prominent in TCs.

Foundation trust hospitals also started to use the system for nearly all their

activity. In the autumn of 2003 the Department of Health published a

consultation document which identified four principal policy directions that

Payment by Results sought to underpin: devolution, choice, plurality and

investment.

Although originally scheduled for all elective, emergency and outpatient

activity from April 2005, the Department of Health’s implementation plan for

Payment by Results was changed significantly following a review of its scope

announced on 10 January 2005 in a letter from the NHS director of finance

and investment (Department of Health, 2005d). This change meant that the

tariff would now only apply to elective activity in 2005/2006 and that non-

elective activity and outpatients would be brought on line in 2006/2007. This

change was a response to the financial rebasing exercise, which all trusts had

been asked to complete before the end of 2004. The ‘last-minute’ move was

seen as an emergency measure to halt a process that could have triggered a

crisis in PCT finances. This was largely because the Department of Health had

based the tariff on activity levels for emergency care in 2003/2004, which

had since increased. Then, more significantly, in early 2006 the Department

of Health had to withdraw the full 2006/07 national tariff only weeks after

publication. The tariff was removed pending work to correct errors in the

original calculations. Some of our case study sites were taken unawares by

the Payment by Results initiative, which undermined their original financial

assumptions and the ongoing uncertainty about the tariff made financial

forecasting problematic.

5.5 NHS Elect

One of the responses to the challenges facing TCs as organisational

innovations was the establishment of NHS Elect. Formed in 2003, NHS Elect

started out as an umbrella organisation representing a small number of TCs,

but now includes other elective care providers besides those that run TCs (see

www.nhselect.org.uk). NHS Elect offered its members:



• networked specialist knowledge and expertise (including arranging visits

to the US to view the surgicenter model)

• patient information and marketing literature, ‘all with a common ‘brand’

and image’

• active marketing of spare TC capacity across the UK

• links with the Department of Health and other national teams.

To commissioning and referring agencies (‘partners’) NHS Elect offers a one-

stop resource for information about the group of TCs it represents, including a

price list for procedures offered by each site compared with the NHS’s

national elective spell-based tariff (NHS Elect, 2004; Timmins, 2003).

Please note that data in the remainder of Section 5.5 is based on a series of

interviews with senior managers in NHS Elect, unless otherwise stated.

5.5.1 Origins and early history

NHS Elect (which at least one early proponent wanted to call ‘NHS Elite’)

developed from a Department of Health sponsored project called ‘First

Movers’, which was established to challenge traditional ways of working

within elective care by bringing teams of doctors to the NHS from overseas.

In 2002/03, one of the ‘First Movers’ initiatives employed overseas and UK-

based surgeons to offer patients in London the choice of having their routine

general surgical and ear nose and throat operations performed more quickly

at the Central Middlesex Hospital’s Ambulatory Care and Diagnostic Centre.

After the end of the project it was felt that it might be useful to have a more

permanent collaboration between a group of NHS trusts who were keen to

prove that separating elective from emergency care was a good idea.

The underlying intention was that NHS Elect would – in some way – form a

chain (‘a franchise arrangement’) in which members would work together and

compete effectively with the independent sector TC chains which were at that

time being established. The model originally adopted was that the TC

members would fund NHS Elect themselves:

It would be worth their while to do that at a reasonably high level because of

NHS Elect bringing in additional activity and showing how to deliver a different

model that would then deliver cost efficiencies as well as a better patient

experience.

(Senior manager, NHS Elect)

NHS Elect had a board that comprised the chief executives of the founding

trusts and the initial plan was that managers employed by NHS Elect would

go and work within TCs, but this was thwarted by governance problems (who

were such managers accountable to: the trust or NHS Elect?). NHS Elect was

established successfully and rapidly, but was less successful at ‘actually

delivering stuff on the ground’ according to both its own managers and our

case study site interviewees during this period. We were unable to find any

public centralised information as to the scale of activity undertaken by NHS

Elect to date, nor about any value added to TCs’ activity by the consortium

arrangement. However, ‘Google’ searching using the phrase ‘NHS Elect’

identified several reports from individual providers or commissioners. For

example, increasing numbers (envisaged as up to 1500) of surgical NHS Elect

patients from Wales were reported as being treated at the Worcester TC



(West Midlands South Strategic Health Authority 2004). Also, the Royal

United Hospitals NHS Trust in Bath, a no-star trust with a troubled recent

history, made a substantial volume of information available on the web. This

revealed that its local PCTs planned to transfer 1000 orthopaedic cases

(presumably in 2003/4 financial year) from Bath to NHS Elect in their efforts

to achieve waiting list targets and implement patient choice.

5.5.2 Re-launch and expansion

After a slow start in its first year of operation, NHS Elect was relaunched with

a reaffirmation of commitment from the chief executives serving on the board

as well as the establishment of a new medical advisory board. NHS Elect was

now expected to provide its members with the following in return for £40,000

from each member organisation:

• It would implement a model of care (‘a draft blueprint for elective care

within TCs which included around 40 recommendations or stipulations’)

derived originally from a visit to one TC by representatives from a US

surgicenter who made a series of best-practice recommendations.

Following on from this, NHS Elect began working on models of care for 15

procedures with the main aim of standardising patient experience across

its member TCs.

• It would establish best-practice links (that is, sharing knowledge)

between the TCs in NHS Elect and provide foreign teams of doctors.

• It would market the spare capacity available in the member TCs.

Interestingly, this included exploring the possibility of selling back spare

NHS capacity to independent sector TCs

• It would brand all of the NHS Elect TCs with a ‘common look’ for example

for patient literature.

Building on its existing member TCs, in 2004 NHS Elect expanded with

explicit Department of Health support to include some 10 TCs. NHS Elect was

mandated to help implement ‘the practical day-to-day stuff’ because, as one

of the NHS Elect managers pointed out:

They’ve got just so much on their plates… that they haven’t got time to wade

through a 99-page ‘step guide’… When you’re running a busy organisation you

just don’t have time to do that.

By the end of 2005, NHS Elect had grown to cover 17 TCs and had become

part of the formal infrastructure of support provided by the Department of

Health Short-Stay Elective Care Programme to the NHS, with the stated aims

being to provide ‘a very practical bundle of support’ which included

• a common experience for patients

• core marketing and consultancy support to members

• opportunities to innovate and spread good practice quickly

• consultancy/accreditation for others

• new opportunities for collaboration with the independent sector.



5.6 Summary

The policy environment we have described evolving over nine years was

highly complex. For NHS-run TCs, their experience has been an uncertain

political climate and apparent conflict between the national and local level,

and this has provided a distinctly (and as far as those at the trust level are

concerned, unforgivably) ‘unreceptive context’ (Greenhalgh et al, 2005) for

innovation, modernisation and change. We see the independent sector TC

programme, Patient Choice and Payment by Results as key influences on the

development of TCs in the NHS, but perhaps the most significant of these has

been the increasing involvement of the independent sector in health care

delivery and the presence of independent sector TCs. The questions facing

NHS-run TCs, confronted by this policy, were:

1 Are independent sector TCs simply here as a driver for change, to shake

up the NHS and drive out inefficiencies, or is there something more

fundamental about to occur, namely the long-term restructuring of

health care provision in England?

2 Are independent sector TCs here to fill short term gaps in NHS capacity,

or is the NHS now competing with the independent sector? (Carvel

2005).

The answer, from the Department of Health, to the latter question seemed

clear:

Choice of elective treatment will both improve the patient experience and

encourage providers to develop more responsive, patient-centred services.

Putting patients in charge of where they are treated means that all providers, IS

or NHS, have to compete for patients and this competition helps drive a patient-

centred service… Once a competitive challenge is introduced it forces the

existing provider to re-examine their processes to perform as well, or better than

the new provider.

(Department of Health, 2006b)

However, the philosophy of expanding independent sector involvement (to

increase choice) has led to incentives and regulation to encourage

independent sector TCs to enter the health care market that have not ensured

a level playing field for NHS services. While independent sector TCs have

guaranteed five-year contracts at above the market rate (to encourage their

involvement in the NHS), spare local NHS capacity has to be funded in the

face of uncertainty about even short-term activity levels. Coupled with the

policy of Patient Choice, such incentives of the private sector have proved a

major threat to the viability of TCs in the NHS, as one of our respondents

pointed out:

It’s all very well saying you have flexibility and choice but that’s the problem;

you’re left with an asset that has a huge overhead that you just can’t meet. And

that’s the taxpayer footing the bill at the end of the day. You need to try and

generate a situation where people do have choice but where you don’t have a

facility like [our TC] that’s half empty. There must be a middle way. You could

probably operate at five per cent under capacity but not at 50 per cent

(Senior manager)

Failure to respond to these uncertainties, as the following sections will show,

led to financial deficits and uncertainty for TCs in the NHS and to the

perception that independent sector TCs have an unfair advantage.



NHS Elect was formed, in part, as an attempt to mitigate the negative effects

of the policy environment in which NHS-run TCs had to operate. One of its

aims was to create a sense of identity for its members – but even this was

more difficult in the NHS than in the private sector as one of the NHS Elect

managers remarked:

One of the advantages that the [independent sector] has is that they can create

a corporate ethos so that everyone who works in their TC understands what the

organisation is about. Within NHS Elect that’s more difficult because they’re not

only part of a TC – although … some of them don’t even realise they are – but

they are also part of [a] trust, they’re also part of the NHS; they’re part of [a]

Hospital. There are all sorts of different affiliations and incentives and drivers.

As a programme of organisational innovation, NHS-run TCs are a good

example of how an unreceptive environment, characterised by high

unpredictability and uncertainty, can significantly undermine a policy

initiative. This environment also includes the historical legacy of perverse

incentives that continues to exert influence in the NHS, and the fact that the

current commissioning process is not sophisticated enough to keep pace with

the speed of reform demanded by the implementation of Patient Choice. The

problem facing many TCs was how to survive in such an environment:

There is an increasing realisation on the part of the policymakers that these

[TCs] were a vehicle for great innovation and change, and now the people who

are left holding the baby are basically in a terrible position that is not largely of

their making. These business cases were signed off. They were predicated on

doing additional work in order to meet planned targets, and the fact is that that

additional work is either going to the independent sector or that the money

somehow isn’t with the commissioners. The commissioning process is too

fragmented to be able to support system-wide SHA facilities. And the response

– which is the automatic response of NHS trusts during financial difficulty – is

shut down, take out capacity. Let’s reduce anything we don’t have to do. Let’s

shrink …most of the places are not the exciting, innovative, energised places

that they were. They are people who are struggling to keep their heads above

water.

Just how successful our sites were in ‘keeping their heads above water’ as

events unfolded is discussed in Section 6.

For further discussion of many of the issues raised in this section, see also

Bate and Robert (2006).



Section 6 Achieving the goals? How the treatment centres evolved

Our aim in this and the following section is to examine how and why the TC

programme evolved in our sample sites in such different ways. It will be

evident from the preceding sections that the exigencies of local circumstances

(the internal and external milieus described in Section 3) and the wider policy

context with its plethora of national initiatives (Section 5) ensured that our

case study TCs had anything but a stable or predictable environment in which

to fulfil their espoused (and actual) objectives, particularly with regard to

their task of introducing innovative models of care. There was major

turbulence as the ground shifted both under the original TC programme and

under most of the TCs’ own local aspirations. It will become clear that most of

the TCs were obliged to depart not only from the central model of TCs as put

forward in the Government ‘frame’ (see Pope and Robert et al 2006), but also

from their own original local intentions (Section 4). We show that this was not

just a matter of TCs and their host trusts reacting contingently to changes in

their environment (what Burgelman (2002) calls ‘autonomous strategic

action’). The local and national TC initiatives could also actually help create

the often adverse and destabilising environmental changes to which TCs

found themselves having to respond. In this way TCs were to some extent

actually, as Weick (2001) describes, ‘enacting’ their adverse environments.

We do not offer this as a criticism but as support for the emerging view of

innovation as a ‘complex responsive process’ (Fonseca, 2002; p.4), evolving,

unpredictable and improvisatory, rather than rational, regulated, controlled

processes (see Section 10 for further discussion of this view). In a similar

vein the emergent process of our sample TCs reveals one of the great

paradoxes of innovation: that the activity of innovating, which aims to create

security and stability is, ironically, that which produces insecurity and

instability (Fonseca, ibid).

In this section we discuss how and why the initial plans rarely worked out as

intended, and the role played by the pressurised nature of the initial

planning, the subsequent impact of shifts in national policy, the state of

relationships with partner organisations, and role of internal developments

and staff changes.

6.1 Planning

6.1.1 Incorrect planning assumptions

As time went on, most of our sites struggled with an inability to predict

accurately what their activity or casemix would be. The TC at Site A was a

poignant example that became a severe financial liability for its host trust; it

faced a deficit of over £10m in 2004/05 and then annual debts of around £5m

per annum over the next five years. As we saw in Section 4, the intention had

been to bring in large numbers of routine patients from a wide geographical

area through the new Patient Choice scheme; and at first it did indeed receive



the lion’s share of patients allocated by that scheme. However, the TC found

itself dealing with fewer routine cases than its had intended:

We thought we could push volume through. Then we started to have a look at

what was actually on the list and it was really quite interesting. The lists are,

by their very nature, full of patients who are old… co-morbidities, complex

patients, social problems… there is quite a bit of complex work in there. So, very

quickly we thought, ‘mmh, this isn’t what we thought it was going to be’, once

we started to break through the waiting list.


A lot of [Site A’s] early problems were they weren’t geared up to deal with

common co-morbidities

(Site A: SHA manager)

It became increasingly clear that once the backlog of waiting list patients had

been cleared not enough patients were being referred to the TC. Within a year

– by which time the number of TC beds had been increased fourfold – the

flow of patients was only half what had been anticipated, and the TC was not

financially viable. The managers began looking for efficiencies, including a

shift from inpatients to day cases, and ways of streamlining services and so

on, ‘altering the way we do things, looking at everything again’. Innovation at

this stage of the TC’s development was being driven not by an idealist drive

towards modernisation, but by opportunism and the sheer pragmatic need to

find new markets and greater efficiencies in order simply to survive. However

this inevitably meant that the casemix began to change. In short, the

planning assumptions about the type of casemix that the TC would attract

turned out to have been completely wrong. So was the idea, it rapidly

transpired, that the TC would treat the majority of patients from the

neighbouring areas. Indeed nearly everything soon conspired to undermine

the original plans, which were retrospectively described by one local senior

manager as having been quite simply ‘a crap business case’. The phrase is an

interesting one, since given the unpredictable nature of the innovation and

the environment one wonders whether a superlative business case

(systematic, measured) would have been any more accurate.

Site F was another of the TCs that suffered from planning assumptions about

activity levels that could not be realised once the TC opened: by the end of

the first year of opening the shortfall was approaching 50 per cent. Most of

our informants were clear that here, too, the problem was rooted in a failure

to think through such questions as the likely referral rates of patients and

hence sources of income:

Well actually financially it’s a mess because the business case never stacked

up in the first place, because nobody really understood where the activity was

to come from. Assumptions were made that it was all going to come from Patient

Choice, or directly from originating trusts, or directly from GPs, but nobody

actually went out there and did a proper market analysis to find out if that is

actually what’s going to happen… There was no continuance of money, no

scenario funding or options funding, nothing like that, which to my mind is not

good business. And surprise, surprise, it hasn’t worked… You know when they

did the capacity modelling here, they looked at three thousand cases – ‘we

need x number of beds and x number of theatres – but what they didn’t do was

look at outpatient activity. So even for two and a half thousand cases I don’t

have enough outpatient capacity, so I have a bottleneck at outpatients. Ooh, it

makes you angry (laughing).




It’s opportunistic money, like a lot of these things are. It just doesn’t strike me

that it was run along good business lines. I wouldn’t start without knowing how

much money you’ve got. No, certainly that’s a real issue. We now are told that

we’re in the red but then again we were never told how much money we had or

didn’t have or were allowed to spend… The real background to it is we were

given very little information, very little knowledge to budget and just rough

figures for, okay, well, you need to do two thousand cases without telling us the

case mix but, have a guess and see what you can get.

(Site F: senior clinical manager)

One of the central problems for TCs was that in order to plan they needed to

predict accurately the likely caseload, but most had to make fairly broad

assumptions on very unsound data. We heard little evidence of there having

been much informed debate at the time that the business cases were being

considered by the higher echelons of the NHS. Typical comments – which the

speaker often illustrated at some point by waving a wetted index finger in the

air – were:

One of the issues with all this is that nobody could ever actually tell us, when

we went to all those strategic meetings and all that sort of thing, what the size

of the waiting list out there is and that whole figure that everyone pins their

maths on is not clear and if it is calculated, it’s not accurate. When you actually

see the patients, a fair proportion are down for the wrong operation or don’t

want the operation at all. So, it’s really stark and very shaky data.


[The planning by the host trust] wasn’t very sophisticated but then the time

frame was such that there wasn’t sufficient time in the process to do that in

terms of working it out and there were a couple of mistakes made. The main

mistake that was made was an assessment made of the lists which was

inaccurate in that 70 per cent of the cases would be minor… 30 per cent would

be [major]. In fact it turned out nearly to be the reverse.

(Site A: senior hospital manager)

At Site B – the only one of our TCs that had not suffered from over-optimistic

initial estimates of activity, but where the TC was an integral ward within the

hospital – plans are still in progress for a stand-alone second phase TC, which

will be more similar in its function to the others in our sample. Discussions

about the planning process for this phase revealed not only that the original

estimates of its capacity had been severely questioned by a formal review

from the Department of Health, but that there seemed to be little good

evidence to support either the larger or the smaller predictions. Despite

repeatedly revisiting their assumptions in the light of the review, the TC

design team saw no reason to reduce the capacity significantly. The senior

managers on the project team told us during a group interview that they

simply had to proceed on some basis, even though they knew there was huge

uncertainty. Not to start building was not an option from the trust’s point of

view as they were relying on the new TC as a key part of the future strategy

for the survival of the trust as whole. The following quotations illustrate not

only the uncertainty that was so widely found around quantitative

assessments of the need for given services, but also the fact that external

events were constantly undermining or eroding those assumptions. In this

case the region was in the midst of struggling to reconfigure services across a

number of trusts, the government had just introduced Payment by Results

(Section 5) which looked likely to have a major but as yet unquantifiable

impact on the financial basis of the new build; and the public- private



partnership requirement to provide up to 15 per cent of patients with care

based in the independent sector was also looming as a possible challenge for

the TC. What is interesting in the following quotations is that some of the

practitioners, like the academics above, are themselves to be found

questioning and doubting the ‘planning approach’ to innovation:

You have to be pragmatic. I think that’s an interesting point, around planning,

as well, when you talk about what planning assumptions we made, what

activity, capacity assumptions we made in this. You can plan to a certain extent

but you only need to look at the strategic health authority around the planning

for orthopaedics. Plans very rarely come to fruition, I find – activity plans in the

NHS. And so you’ve just got to plan it the best you can and then move forward

and, like [senior manager 2] said, it’s never going to be perfect.

(Site B: senior manager 1)

If we took this capacity planning round and said, right, that’s the baseline, you

can guarantee that in two years’ time it will be something completely different

or, like we said before, you can wait another two years and do nothing and

then in two years that will be different again.

(Site B: senior manager 2)

Site D ran into problems, some of which might perhaps have been predicted

with a more careful analysis of the need for health services in that region, but

others of which arguably could never have been anticipated because of the

time-lapse that always occurs between the conception and implementation of

an innovation. The TC ran at around 65 per cent capacity until it eventually

met its original monthly throughput target some 20 months after opening.

The rationale for the original model had been arrived at several years before

the TC programme was launched, and had not been adequately revisited or

tested in the rush to obtain the funding to open the unit as part of that

programme. In the event, waiting lists fell dramatically as other TCs opened

nearby both in the NHS and the independent sector, which again meant that

there was less work to be done than had been envisaged. Moreover, Site D’s

TC proved to be more expensive than its competitors: the average price for

one standard operation within that specialty was £4500, but at Site D was

£5500. This was partly due to predictably high capital charges, rates and

service costs, but there was also an unanticipated (though possibly

predictable) shortage of qualified staff requiring the use of expensive agency

staff to fill vacant posts. (Mistaken assumptions about the costs and savings

from changes in staffing levels also undermined the intended switch to a

nurse-led service – see Section 7). The unanticipated extra costs of the TC

were also partly attributable to the high overheads accruing from its

associated high dependency care unit that was greatly underused since – in

contrast to Site A, which found itself dealing with unexpectedly complex

patients – the casemix at Site D had been much more straightforward and

routine than had been planned for. There was therefore little call for the extra

facilities that had been committed to dealing with more difficult cases.

Moreover the plans for the routine patients were formulated on lengths of

stay that had been based on US experience and could not – or would not – be

adhered to by the senior medical staff, which also added to the costs. There

were also some early teething problems with essential off-site support

services that required outsourcing, which added to the financial loss totalling

more than £4m in the first year. This devastating cocktail of problems was

compounded by a completely unexpected policy initiative six months after the



TC officially opened when the government introduced practice-based

commissioning coupled with the introduction of the G-Supp scheme (see

Section 5.2.1). This made it cheaper for the local PCT commissioners to send

the patients to the independent sector or to other trusts, which – inevitably –

they did.

Site C's original plans suffered from a different kind of unexpected setback.

This TC's business case relied on activity from neighbouring PCTs that had not

previously sent patients to Site C, but were now determined to do so because

of poor performance in their traditional provider hospital. Shortly before the

TC was due to open, these PCTs revised their commissioning plans – not

because of any dissatisfaction with Site C, but because their previous provider

had now shown itself capable of handling the work satisfactorily. This

dramatically reduced the projected activity for Site C and was a huge blow as

no contingency had been made for such an eventuality in the TC's plans. And

yet, as one manager who had inherited that situation put it, it might have

been wiser not to expect the assumptions to be accurate:

The plan assumptions we were using were never as robust as they thought they

were, but I’ve been very clear all along – the experience from other treatment

centres is it don’t matter how good your commissioners or how clear their

intentions are… what actually walks through the door in terms of patients at the

end of the day is totally different.


Site H also appears to have had some very inaccurate capacity planning

assumptions underpinning its original business plan for the TC. Planned

activity level had been put by the finance and information departments at

around 3500 FCEs per annum, based on (a) existing workloads, (b) rate of

referrals, (c) likely growth and (d) national assumptions. But the team who

had been employed to run the TC some time after these figures had been

posited, saw the figures as ‘unrealistic or just plain wrong’ Their view was

that the capacity estimates for the TC might be over-inflated by as much as

300 per cent. They were also concerned to rectify the omission in the original

plans of a dedicated operating theatre, which they regarded as a missed

opportunity that was – in the event – turning out to be essential for the

success of the TC. (One manager told us that if this theatre failed to open by

the end of 2006, ‘we’re stuffed’.) Reflecting on how the plans for the TC at

Site H had come about, an experienced SHA manager suggested a

comparison with other NHS initiatives they had been involved with, such as

NHS walk-in centres:

You have somebody that comes up with an idea. That idea then gets fleshed

out and has to be knitted back towards NHS policy mainstream. And it then

gets knitted into our wider scarf than the little tiny bit of scarf that was

originally being knitted. So it was like all of that with NHS. You then developed

a branding, almost, and you developed a brand for both walk-in centres and

treatment centres. The problem is that the brand that you end up with doesn’t

necessarily fit the bid that was originally around the initial stages of the

process.

(Site H: SHA senior manager)

Nevertheless, despite the overestimate of likely activity, which meant that the

TC was soon running at between a quarter and a third of the expected

throughput –soon after opening it was already completely empty on some

days – it was able to adapt and increase the numbers steadily, though still



well short of the original expectations. Meanwhile a financial shortfall in the

host trust meant that in any case the whole project had to be scaled down.

Site E also found that they had been over-optimistic in their expected

throughput, thanks also to poor planning assumptions. Initially they planned

to receive patients from a geographical area beyond the boundaries of the

host trust but in reality, by their second year of opening, the distant locations

had either not signed up to sending patients or had found closer, cheaper,

more appropriate alternatives. As one PCT representative told us:

But the main problem we’re having is the relatively restrictive list of procedures

and the prices they charge making them not particularly attractive and certainly

no more attractive than some of the [local] private sector. Also, the private

sector, even if they’re slightly more expensive [may] do a volume deal.

(Site E: PCT manager)

As in Site H, the team was able to adapt to the problem, in this case by

successfully marketing with other distant commissioners through engagement

with national networks. Likewise Site G was another that soon found itself

with spare capacity and underutilised facilities and staff. This site had initially

wanted a day case unit that would serve its local population, but had

opportunistically expanded the scale of its plans to secure TC funding. As in

Site A, the case for this rested on an assumption that the TC would attract

patients from a much larger geographical area. However, demand ‘dried up’,

partly as the sending trusts engaged in their own ‘waiting list busting’ but

also because patients proved less willing to travel than anticipated and,

perhaps more importantly, these distant trusts were extremely resistant to

the idea of sending their patients to an unknown facility. (Waiting lists are

often seen as being ‘owned’ by the consultant who makes the decision to

operate. These decision-makers were often unhappy with their patients going

elsewhere. In the most extreme example of this a consultant based at a trust

engaged to send patients to Site G wrote to his patients expressing concern.)

In short, seven of our eight sites found themselves in difficulties because their

initial assumptions about the likely numbers and/or casemix of patients

turned out for one reason or another to have been over-optimistic or

erroneous. The eighth was a very different kind of unit, integral with the host

trust and acting as a capacitor to increase patient turnover across the whole

surgical division, and excess capacity was therefore never part of the picture.

Even at that site, however, the planning for the phase two stand-alone TC has

involved some major disagreements based on uncertainty about its eventual

optimal size that remained unresolved.

In the turbulent and often unpredictable world of the NHS, planning seemed

casual, and apparently little care was taken to test the assumptions of the

business cases or draw up contingency plans. It is striking how often and how

badly so many of our case study sites got it wrong, and how much of the

subsequent effort was spent in trying to rectify the consequent difficulties,

difficulties that mean that about half of our sample, as things currently

appear, the innovations will not be able to survive in their present form, if

they survive at all.

Why did the eventual course of the TCs’ workload differ so dramatically from

that which had been assumed at the planning stage? The poor information

and lack of predictive capability discussed above clearly had a huge impact



but our findings also suggest a number of other reasons which we discuss in

turn below:

• pressure (both from external demands and internal enthusiasm) to move

fast at the bidding stage, and a tendency to ‘cut corners’

• changing circumstances, not all of which were unpredictable, and the

lack of adequate contingency plans

• lack of support from external partners (including PCTs, SHA, trusts) who

were not sufficiently engaged with the project or had conflicting

priorities, and, linked to this, a lack of strategic planning across partners

• inability to realise the ambition to draw in patients from distant sites (an

aspect of ‘market failure’ as described by Bate and Robert, 2006)

• inadequate support from internal stakeholders (including clinicians and

managers in the TC but also internal systems and contractors)

• sometimes ambivalent relationships with the host trust.

6.1.2 Pressurised planning

As we saw in Section 4, the pressures from all levels of the service made it

imperative to increase elective capacity across England within a short

timescale. At most TCs, the host trust needed to capitalise on the opportunity

to acquire additional capital funding, which also had to be competed for

within a short timescale. The PCTs, SHA and trusts felt that they needed to

act quickly so as to hit government targets. In some places senior leaders

wanted to be seen to be at the forefront of this innovation, and therefore

sought to secure a number of TCs. The Department of Health and the

government wanted to implement the TC programme so that they could

demonstrate that the NHS was modernising at a rapid pace. And within the

TCs and their trusts, the local idealists were anxious to get on and introduce

as soon as practicable their innovative ideas to improve care. These and other

pressures conspired inevitably to produce a rushed job that ignored (or more

accurately perhaps, chose to ignore) the shakiness of many of the basic

assumptions. And all of this was unfolding rapidly in a context of impossibly

tight deadlines.

Things happened so quickly in that we were waiting for a long time to find out

how much money we were going to get, then all of a sudden a decision was

made, and ‘it’s OK, here you go, now open the [diagnosis and treatment centre]

and make it work by Monday.


It all started ‘on the back of an envelope’. [A senior clinical manager] was

accosted by the operational director in the street, who said ‘It’s all very exciting

because we’ve been made a first wave [diagnosis and treatment centre].’ ‘Great,

but what’s that?’


The conversation I had with [the Department of Health] was quite bizarre. He

said, ‘I hear you can open a day case unit treatment centre quickly?’ I said, ‘Oh

yes, we’ve got the shell, we could do it.’ ‘How quickly could you do it?’ ‘How

quickly would you like it?’ ‘Well, the Prime Minister wants it tomorrow to sort

out the [local trust problem]. He wants all these two-year waits sorted in 18

months.’ ‘In five and a half months we’d probably do it if you give us the

money, [X] million pounds, that’s what we need and you have the treatment

centre, I can open and we’ll bring the overseas teams in and we can do it.




[The planning and modelling] was done by [X]; it wasn’t very sophisticated but

then the timeframe was such that there wasn’t sufficient time in the process to

do that in terms of working it out and there were a couple of mistakes made.


One site which did not appear to have quite such a pressurised planning

process was Site D. Some of the planning behind this TC had been under way

since the mid 1990s, (albeit in a slightly different form). Like the other sites

there was some opportunism in linking these plans to the TC programme, but

it is striking that simply having this additional planning time did not prevent

them encountering the very same problem of uncertain workloads and failing

to adequately adapt to the changing wider context. Knowing as we do the

problems that came later because of pressurised ‘back of an envelope’

planning in several of the sites it would be easy to say that more ‘slack’ in the

system, especially in the early stages, would have made a difference.

However, given that it seemed everyone would gain from having a TC, it

would probably have taken a very brave person at the time to intervene and

slow things down in order to allow more time for planning and reflection. The

presence of Site D as a disconfirming case here also suggests that it may be

the quality of the planning, not the time in which you have to do it, that

matters. The issue that may be of greater interest and relevance to theorists,

policymakers and practitioners is how to avoid ‘groupthink’ (Janis, 1972) and

the collusion that accompanies an innovation that appears to be all benefits

and no downsides (the colloquial ‘no-brainer’ - a term often heard in

discussions about TCs or at least the philosophy underpinning TCs).

6.2 The shifting ground

We saw in Section 5 how a plethora of initiatives from central Government

affected the TC programme. This was not just a matter of competing priorities

for managers. Nor was it the tendency for some managers to (as was often

said) take their eye off the ball because a new initiative now loomed larger in

their field of vision. Such tensions are taken as read in senior management,

and were fully to be expected in this instance. However there was a clear

impression among many of our informants that the NHS had been going

through a particularly intense period of change and reorganisation since the

NHS Plan, which itself had followed a long series of reorganisations under the

previous administration. There was therefore a strong feeling of ‘battle

weariness’ or change fatigue among many managers and clinicians. There

was often also a lack of continuity and corporate memory that may have

contributed to the failures in adequate planning and networking that might

otherwise have helped to avoid the mistakes that occurred. But one thing was

particularly specific about this particular innovation: many of the

government’s parallel initiatives actually worked to undermine its success.

The following three policies were seen as presenting a special threat to the

evolving NHS-run TCs (see Section 5 for the background to each of these).

6.2.1 The rise of independent sector treatment centres

The Government push to involve the independent sector more in the delivery

of care for NHS patients and the independent sector TC programme in



particular had huge implications for some TCs in the NHS. An internal report

for one of our sites suggested that:

The net effect of the private sector, independent and NHS treatment centres

combined with the activity currently taking place in host trusts will result in a

massive over capacity in the market. This is the biggest threat to [the trust’s]

survival.

(Site A: internal report 2004)

A view that was reiterated by one of our respondents at this site:

They insist on pursuing this independent sector nonsense, and I think that’s

what we find so frustrating. I think from the government’s point of view, they

just say, we’ve just got to increase the capacity, we’ve made this commitment to

an independent sector, 15 per cent or 20 per cent, or whatever, and everyone’s

work has got to go through the independent sector, and that’s the promise we’ve

made. Well, that’s fine, but then you are going to lose some NHS treatment

centres as a result, so they’ve got to decide somehow, how that’s going to work,

because you’re not going to be able to have it every way.

(Site A: clinical manager)

The impact of the threat from the independent sector should not be

underestimated. Indeed in the later phase of our fieldwork at least three of

our sites (A, D and H) were considering selling capacity to the independent

sector or entering into some form of partnership with them:

We believe that one of the longer term solutions is to work with a private sector

partner in partnership or to hand it over to them and we’d provide the clinical

services. Or not even that necessarily ... Or even to give them a part of the

facility to run independently. All options are open and have been explored and

I’m sure will continue to be explored… We’ve had [names various independent

sector companies, international and national]; they’ve all been round. At the

moment it’s a failing business.


In 2005 Site D entered into discussions about leasing the TC to the

independent sector; a plan that the trust explicitly linked to the government

policy of promoting private sector provision and increasing plurality. One of

the local PCT commissioners concurred:

Hence perhaps the model of the NHS treatment centre may not be the most

appropriate. A public company could do it for if not less money, better value for

money, I think because in the NHS it tends to be rather difficult to change

structures, and to change direction because of the nature of the beast. It’s a big,

complex organisation and it takes a hell of a lot of time to turn it round or to go

in a slightly different direction. Smaller organisations tend to be fleet of foot;

hence things can happen very much quicker. I mean I have every confidence

that eventually we will have a multitude of treatment centres; I think the model

is wonderful. And we’ll be able to get services for our population from any of

those centres. The advantage of doing it outside the NHS is it breaks the

monopoly of the consultants, the stranglehold of the consultants, which I don’t

think is an appropriate model. It doesn’t do anything for patient care, but

similarly we’re moving towards having a multitude of different types of

provision in primary care as well to break the power of the general

practitioners. I think that’s fine as well.

(Site D: PCT senior manager)

While this transfer of an NHS-run TC to the independent sector appeared to

have the support of the Department of Health, it met considerable opposition

from other quarters. Pressure groups leaked information to the press and



local campaigners challenged the trust to explain the reasons behind the

plans with the result that the plans were postponed. At this site, as at Site C,

there was also considerable trade union opposition to the increasing

involvement of the independent sector, which was viewed as ‘privatisation by

stealth’ and in both sites this led to national level union campaigning on this

issue.

6.2.2 Patient Choice

At least four of the sites (A, D, F and G) anticipated numbers of ‘Choice’

patients which simply did not materialise in the early days of the unit. Part of

this as we have already noted (Section 5) was because patients were

reluctant to exercise such choices, as one of the PCT senior mangers

explained:

I think that when targets are set people don’t really appreciate how difficult it is

even to actually be ringing up patients and offering them choice, and the

patients are wondering why they’re being offered the choice and don’t quite

understand. We’ve had that experience within NHS. The patients say why is

this person phoning me, who are, why do they want to move me. No, I don’t,

thank you very much.

(Site F: PCT senior manger)

Perhaps ironically the Patient Choice initiative was undermined by the

apparent success of other waiting-list-reducing policies:

I think this year we probably only sent about, and [had] accepted, I think about

190 cases from Patient Choice and it really has fallen off big-time, I mean we

were doing several hundreds last year. So it’s a big drop-off but it’s obvious

that, as the waiting list gets under what an individual perceives to be not

unreasonable, I think probably in the six month area, I don’t think three to six

months is a big deal to an individual, but nevertheless you get less take-up,

and people are unwilling to travel and they’re unwilling, certainly once they’re

in the system, to change consultant.

(Site F: senior manager, neighbouring trust)

Some of our TCs also reported that prevarication by ‘sending’ trusts reduced

the numbers of such patients:

We’re reliant on them giving us the names from [geographically more distant

trust] and they’ve been very slow at sorting out the waiting lists and actually

identifying the patients. So until we actually get the patients to ring up and start

booking, there’s nothing we can and [they] have been very slow to get those

lists of patients across to us.


That said, not all the case study TCs were expecting the Patient Choice

initiative to have any impact on them:

I think also the impact of the [Patient] Choice initiative will be very minimal in

the early stages because we’re not planning to have any six month plus waiters

by the trigger dates for the initial phase and choice. The other issue around

December 2005 and patients being offered a choice, the risk of losing patients

when offered choice we believe to be fairly small… [Describes a previous move

of surgery site X to site Y]… There’s no evidence that people are switching

away. The second I suppose is the type of population that we have. The

majority of the population is not the most mobile. There’s a feeling that we’re

not going to lose it, and I suppose there is a third. We’re going to be offering

brand spanking new facilities. Brand new facilities are more likely to attract



than deter patients. So, given those sorts of things, who knows what will

happen, but we’re not expecting to have a significant loss of patients.


6.2.3 Payment by Results

Payment by Results represented both an opportunity and a threat to the TCs.

The perceived complexity of the proposed tariff coupled with a lack of

understanding as to how the new financial system would work meant that

some felt that the system would ‘be a shock to some… the message had not got

through yet even though the TC is where big gains could be made’


Thus at Site G there was recognition that the TC could potentially benefit

from the new tariff payment system as their costs were some 10 per cent

under the initial Payment by Results tariff charges (largely due to the

historically small size of the trust and lower than average staffing costs). Yet

for others there was concern that Payment by Results would prove to be

another challenge to the viability of TCs:

Payment by Results has not gone live in the way that we expected it to. [Trust

X] is still unique as an early implementer of Payment by Results and so it is

starting to map activity under the new system but that’s causing problems

already in the current financial year because the commissioned activity that

we’ve placed with [X] is now more expensive and that’s partially to do with

Payment by Results and the tariff… again it still points to the fact that the

information systems are poor… And is it that there’s resistance in the system?

That’s probably why Payment by Results hasn’t gone live. There are actually

secondary providers who perhaps suddenly see that they could lose money.

(Site F: PCT senior manager).

The definition of the interactive Payment by Results of organisations have been

interpreted for this organisation alone, and every other organisation in the

country. Every other acute trust in the country will have gone through this

examination process and maybe some of them have seen the situation, as far

as they’re concerned, remain fairly stable with these different interpretations

and different definitions as various versions of PbR [Payment by Results] have

been issued from the centre but our scenario has gone from almost euphoria to

muted optimism to being downright pissed off.

(Site B senior manager 1)

Interviewer: Why is that? Because of the changing levels of payment or

commissioning?

Yes. PbR, as originally thought, as (senior manager 1) says, it was going to be

used as a very low-cost hospital. As definitions have changed and various

approaches have been put into the system to assist areas of the country which

might have done badly out of Payment by Results.

(Site B senior manager 2)

6.3 Relationships

6.3.1 External partners

Where within the system did the weaknesses that led to the failures in

planning and implementing TCs lie? It was not always possible – short of a



full-blown inquiry – to gain more than an impression: every level, from

government (as we have seen in the preceding section) through the layers of

the NHS down to the TCs themselves was implicated in many of the sites. We

often found that there had been a lack of collaboration and support from

external organisations in the NHS. Key failures in collaboration included

neighbouring trusts that would otherwise have been treating those patients

(usually because they were unwilling to transfer significant levels of their

activity); PCTs – particularly those beyond the immediate host trust – who

did not choose to commission the expected levels of patient activity (often

because of alternative providers such as independent sector TCs, but also

because expenditure on the conditions treated in NHS-run TCs were not seen

as a relative priority); the ‘host’ PCTs who may not have provided the

expected support; and to some extent the SHAs who were unable to co-

ordinate strategically the distribution of patients between different

commissioners and providers. We will examine here how and why these

relationships failed and later go on to discuss the relationship between the

TCs and their host trusts.

6.3.2 Antagonistic relations

There were several possible reasons why the TCs may have been let down by

these potential partnerships, but sometimes the host trust TC had simply not

put enough effort into wooing and involving these potential partners. Indeed

in some of the sites, as our descriptions of the external milieus of the TCs and

their host trusts in Section 3 will have foreshadowed, the host trust and TC

seemed almost to have deliberately antagonised key organisations. Site A for

example was frequently accused of having excluded the local health economy

from its planning to the extent that neighbouring trusts felt threatened by it

and became hostile (in the case of PCTs these feelings were exacerbated by

their being top-sliced to provide funding for the TC). This attitude made trusts

much less inclined to send ‘their’ patients to a hospital that they believed

might as a result undermine their own viability, or to help find a local

economy solution to the resulting problem of overcapacity.

In local hospitals as well as PCTs there was also a lot of ill feeling about the

way the TC had been set up without involving them in the planning; there

was concern that if the TC succeeded it might fuel ‘predatory ambitions’ and

there was resentment about TCs:

People get very loyal to their organisations – chief execs as well as consultants

– and have not been able to see a greater good. And I think that’s a shame

because I think it’s a fantastic facility. I think it could do a whole load more

work. I think it could probably cover most of elective for the sector. I don’t know

the actual numbers, but it could absolutely cream through a lot. We’d get the

qualitative outcomes if more was going through there and we had a pool of

consultants there all with a subspecialty. Fantastic support for each consultant.

Massive research-base. Great patient outcomes. I hope in time that will be seen

as a resource. But I don’t know why it’s not been perceived in that way. I think

it’s just been seen as the big future hospital trying to steal the work of the other

hospitals, which I don’t think was the intention. We certainly gained from it. I

think patients have gained from it. But I’m not quite sure why the buttons

haven’t been pressed. Maybe they haven’t heard or don’t want to, and they

think we’ve got a bit parochial. I don’t know.

(Site A: senior manager, neighbouring trust)



Local trusts became unwilling to refer patients because they themselves were

experiencing financial deficits that made it more attractive to use their own

beds to treat patients from a particular specialty. Competing government

initiatives such as Patient Choice and G-Supp sometimes made it preferable

to refer patients to the private sector. Such attitudes and actions left the TCs

floundering. Site F, as will have been clear (Section 3.1) had done almost

nothing to ensure that the neighbouring trusts and commissioners would send

patients to them in preference to all of the other alternatives that were

available. Perhaps their assumption was that their reputation would speak for

itself. If it did, it seemed more to confirm among others their reputation for

arrogance. Moreover the trust’s frank entrepreneurialism led the local health

economy to regard it with suspicion:

The secondary issue which kind of complicates all this is the thing around

activity because a large part of determining a claim was counting things that

had previously not been counted, and counting things in a different way to the

way in which they had previously been counted in order to attract a higher

value invoice. So actually a lot of the work of the PCT was just a bit like getting

a bill from a dodgy restaurant, really, or a dodgy supplier and once you

actually go through the itemised receipt and work out what you’re getting,

you’re not necessarily getting what people say you are getting.

(Site F: SHA manager)

A vicious cycle rapidly developed where the local PCTs and trusts were

reluctant to work with the TC and the TC and its host trust became

increasingly suspicious that the nearby health economies were just looking

after their own interests and sending only ‘rubbish patients’ and were:

...pretty useless really, because of the fundamental premise of people refusing

to send us patients because they didn’t want to lose the income has been the

big stumbling block, and still is. So, the only people who send us money are

those who stand to be so badly in breach, it’s their only way out of a cleft stick.

So, we get sent… people where it’s got to be done in the next two weeks, and

some of them, there’s just junk. Some of it really is appalling.

Interviewer:So they were cherry picking?

Oh yes, I mean on a huge scale.


[Patient Choice] patients were coming to us in batches rather than a continuous

stream, so as soon as you get patients coming to you in batches you get

bottlenecks in the system…. It’s completely against the philosophy of a

(diagnosis and treatment centre) where everything is totally predictable and

booked.


6.4 Competition and market forces

6.4.1 The lack of a level playing field

Sometimes the explanation for such activity was simple: market forces.

Actors in the local health economies were mainly responding to market forces

and making decisions to maximise their efficiencies that were understandable

in that light. At Site D, for example, the government-led change in

commissioning arrangements, which included practice-based commissioning,



made it inevitable that the local PCTs would take advantage of G-Supp to

send patients to the private sector because that was less expensive than the

TC. But such market forces, coupled with the pressure to make the best use

of the Patient Choice initiative to reduce waiting lists, did lead to some

perverse outcomes (such as patients being sent to the private sector or even

overseas for operations when these could have been accommodated in

several nearby TCs or other hospitals that were underused).

I tell you, the other day I found out and could not believe it that [nearby

Hospital M] said that through the Patient Choice initiative there is money to

send a certain number of their hip and knee patients overseas, which is just

crazy. You know, we’ve got the capacity to do it, [Hospital K] has got the

capacity to do it, I would imagine [Hospital L] have got the capacity to it – and

you’re sending them overseas!

(Senior manager)

Such consequences might in theory have been mitigated by some kind of

brokering or ‘regulating’ activity by agencies such as the SHA or local Patient

Choice schemes. And indeed at some of our sites, this did happen. For

example at Site A, the SHA eventually helped to provide additional support to

try and minimise the financial deficit. But the SHA were limited in what they

could achieve. Ideally the TC would have liked much more support than was

possible:

The SHA needs to look at what the capacity … is in the system and say right,

either we send a thick, and much larger chunk to [Site A], or we close [Site A],

and it all stays back at the host trust, I think they need to dictate that to a

certain extent, and then say to the trust, right, you need to do, whatever. To be

fair, a lot of the trusts are sending a lot more, but then the PCTs need to also be

told, all the [specialty] work goes to [Site A], and that’s where it’s funded. So, I

think it needs to be a strategic health authority decision, because we can’t go

back to the PCTs and say, no sorry, you have to keep treating the patients,

because if [Site A] treat them, [Site A] want to get paid for it.


One of the difficulties facing the SHAs was that they too were undergoing

organisational change in this period, and many were still finding their feet as

organisations. While there were occasional instances of the SHAs supporting

the TCs (for example helping to identify a TC project lead at Site C) there was

little evidence that they were able to provide effective strategic planning or

assistance: as one senior manager explained:

We’ve been to the strategic health authority a hundred times to tell them that

you’ve got to help to market manage this: here is this facility, here are the

waiting lists, this is what you are spending globally… this is bonkers!

(Senior manager)

At Site F the SHA claimed it had tried to be facilitative and supportive, but the

trust would have none of it. They elected not to engage in detailed

discussions with the SHA, whose influence in any case had diminished since

PCTs had taken over the commissioning role:

Well, I think [Site F] probably wouldn’t pay a great deal of attention to us …[…] I

don’t think they see the SHA as being in a position to provide them with a great

deal of anything useful other than some sort of system problems that they

would like us to fix.

(Site F: SHA senior manager 1)



So far they’ve not really shared that detail because they still see themselves as

fairly unique and not accountable to the PCT or to the SHA; they think that

some of those discussions were only with the chief exec but they didn’t realise

that if they don’t have these conversations with the commissioning process then

they lose out on the opportunity to discuss them in a different way.

(Site F: SHA senior manager 2)

Nor did Site F have good relationships with another crucial mechanism that

was intended to facilitate the ‘market’: the Patient Choice scheme. Patients

had also failed to materialise in the expected way from this source:

They [the Patient Choice agency] are probably not quite sure what we’re doing

and it means we’ve got a relationship where it’s a little bit confrontational. So

much so, actually, that I had a very difficult meeting with their director the other

day who basically accused us of being arrogant.


The trust’s failure to link up collaboratively with the local health economy

doubtless contributed to its TC’s demise, although it is by no means clear that

greater collaboration – even had it been possible given the cultural and

economic climate in that part of the NHS – would have averted the eventual

outcome. Nevertheless it is difficult to escape the conclusion that a more

collaborative approach from the initial planning stage with the Patient Choice

scheme – if not the SHA – might have helped prevent the problems from

developing in the first place.

Such a competitive attitude, which contributed to the demise of Site F, was

also seen elsewhere as a necessary part of modern NHS management. The

prevailing view at trust level was that every trust had to look out for its own

future, rather than consider the needs of the whole of the local health

economy. For example:

The strategic health authority in particular, and you’ve spoken to them, have a

real, real mindset of ‘Oh God, we’re going to have [TCs] everywhere!’ and in

particular they’re looking at this scheme and saying, ‘Well, do we really need

it?’ As I say, that’s a decision which is all very well if you’re going to be happy

in a NHS family but it’s a different decision if you’re an independent foundation

trust looking to maintain an income… There’s a problem with being stuck in

oldspeak. It seems to have passed the strategic health authority by

intellectually that we’re a different business model these days. We’re not going

to be one big happy NHS family. We might have been in 1997 but policy is that

we’re competing organisations now and, not only that, we are much more

fiercely competing organisations. It’s completely different. That kind of

opportunity [i.e. building a TC despite potential overcapacity] is compatible with

the policy. They just haven’t grasped it yet.


6.4.2 PCTs and SHAs

Nevertheless, despite this marked thrust towards a competitive ethos

between organisations, some TCs did manage to establish good relations with

the organisations in their milieu, especially the PCTs, and this often seemed

to yield positive dividends. At Site C, for example, good links with the main

PCT – both personal and through formal committees – were important to

ensuring appropriate patient flows:

Working has become easier with the appointment of this deputy director of

commissioning. When I started off she wasn’t there so I feel like I’ve got a



buddy on the other side now and that’s just been really useful. We can just

sit down and thrash it out and work out what we’re going to do. It’s very

supportive and she’s been good news… Those [formal] forums have given some

key focuses around things like length of stay, referral rates coming in, and it’s

always by trust as a whole and then we break it down into referring PCTs.

(Site C: senior manager, emphasis added)

At Site C, as at Site D, some of the new ways of working (see Section 7)

revolved around shorter lengths of stay and more rehabilitation (in particular

physiotherapy for patients undergoing joint replacement). This required

working closely with the PCT managers and clinicians responsible for these

aspects of care, and allaying their concerns:

But I feel that I can appreciate how people who are outside [Site D TC] actually

feel a bit threatened by change. I can appreciate that and they think we’re going

to be sending home all these people who are unsafe to be discharged. This is

what they’re afraid of: that we’re going to make a complete dog’s dinner of it

and they’re going to have to pick up the pieces. I think that’s the bottom line.

They are terrified of that. But the only way we can prove to them otherwise is

by our lift-off period, being particularly careful about that, and also being very

meticulous about our liaison with them and I hope that we will be able to prove

that to them.

(Site D: manager)

However the closeness could be a double-edged sword where, for example,

PCT managers knew the trust managers well enough to observe what they

saw as their failings:

I’m very concerned about capability and capacity at the moment. I observed a

[TC management] team that look extremely stressed out… I think it’s, they’re all

home grown. So, the team hasn’t changed fundamentally… Fundamentally the

people running the organisation were the people running the organisation two

years ago… When you’ve been doing something the way you’ve been doing it

and it ain’t broke, you do have an attitude, why am I going to fix it?

(Site C: SHA manager)

Site E was an example of a TC with good links with local PCTs and SHA, but

to some extent it was easier for them since all parties were keen to reinstate

some kind of hospital facility at that site, and therefore had an interest in

supporting the TC. However, there were some criticisms from further afield

about Site E’s business practices. Some outlying commissioners did not have

such close ties as the more local PCTs; none were represented on the clinical

board and they either dealt with the TC manager individually or through a

brokering trust (for example one PCT in another county bought services from

the TC through their local acute trust). These distant PCTs had mixed feelings

about the usefulness of the TC. Some found it a welcome addition to their

range of providers while others were less positive, feeling disadvantaged in

negotiations related to price and case-mix and consequently preferring to use

services closer to home. They eventually withdrew the contract in favour of

local, more extensive, cheaper provision that had been developed there. Site

E was also keen to work with the independent sector; it sold part of its space

to a private health care organisation and made great play of a developing

partnership, which helped considerably in its financial profile and survival. In

short, the key to Site E’s survival was firstly its ability to forge good links with

potential partners that would supply it with patients, and secondly to be

flexible in response to their needs, not only in the sectors served but also in



the types of facilities offered (for example moving from day to short stay

surgery).

Site H had mixed relationships with the local PCTs. One of the two local PCTs

was closely involved with TC development, but the other barely knew

anything about it. We found very little understanding locally outside the host

trust itself about this TC and how it was going to operate alongside existing

services, and it was clear that the planning had been very inward-looking at

the TC’s host trust. The managers at the trust justified this by suggesting

that:

PCTs are too new aren’t they? They don’t know what’s happening either. I

mean if you can find anybody in the local PCT who know what a treatment

centre is then you’re very lucky.

(Site H: senior clinical manager)

Site C found itself short of patients when the contracts representing over half

its proposed activity were withdrawn by two (of three) commissioning PCTs.

These PCTs had been unhappy with their usual local provider and had

contracted with Site C. However some way into this process both PCTs

decided to go back to their original provider. This forced the TC to rethink

both activity and casemix:

We’re opening 18 beds on [date] which are going to the orthopaedics and the

other 18 beds are undecided. [In] the original plan that was all surgical, it

wasn’t orthopaedics; so things have really shifted there and when you take into

account that we appointed a ward manager to that ward who was a non-

orthopaedic nurse, because it was going to be a surgical ward, there are some

real tangible decisions that have been made which are an indication that we

could never have guessed just how orthopaedic this beast was going to become.


There was perhaps understandably considerable anger and bitterness directed

at the two PCTs concerned, a sense that trust’had been broken. However for a

few people, including one of the senior managers this was just another

setback to be overcome, ideally by focusing on more positive relationships

with the remaining PCT, and developing new links in the wider health

economy. The latter entailed forging links with national networks as well as

marketing the TC more effectively and more widely, and this vision was

shared by one of the SHA managers:

Empower yourselves guys. There’s more than one commissioner out there. You

know, why do we want to put all our eggs in one basket, and actually you

should be really marketable as a treatment centre. If you’re doing things

differently, endorse it, so why are you worrying? You know, get out there and

get the business. So, I’ve been trying to, rather than licking wounds and feeling

very bruised by the whole episode, I’d rather people decide to get a grip and

push forward.

(Site C: SHA manager)

However carefully the TC tried to cultivate relationships they sometimes,

naturally, became strained because of problems they could not have

anticipated. For example at Site G it later became clear that the PCTs would

not be able to pay for the extra work being done as agreed by the TC

(essentially the TC had overperformed and the PCT was overspent). As a

result, relations with the local PCT in particular became very strained and

confrontational over the following year.



The difficulty over the finances, it’s a nightmare. And that always puts tensions

into working relationships. We had a contract for over performance this year

and it was signed up some time last summer – we’d been over-performing [for

the PCT], really only in the last four or five weeks [PCT] discovered [we] can’t

fake over-performance, worth two, two and a half million. So we now have a

two million problem that we didn’t think we had, which has seriously pissed off

[names mangers] and others.


The host trust began actively to market the TC capacity elsewhere with some

limited success. However the legacy of this episode was a continued and

significant financial deficit.

Nevertheless, in conclusion, it seemed that good external relations with the

‘customers’ (PCTs, trusts) and ‘regulators’ (SHAs, Patient Choice) could help

to ensure an adequate flow of patients. Some TCs may have failed to attract

as many patients as they had intended because they had not nurtured the

relationship with the other members of their local health economy. This was a

contributory factor at the planning stage, when a more careful exploration

(and perhaps ‘warming up’) of the likely market could have been discussed,

and the knock-on effects of other forthcoming market developments might

have become clearer. And closer links may also have been particularly helpful

later when the collaborative management of the market that may have been

the best way forward sometimes turned out instead to be impossible because

the necessary trusted relationships had not been cultivated. This in turn was

at least partly attributable to two aspects of general NHS policy: the

encouragement of competition, and the lack of consistency and continuity of

relationships that resulted from the frequent organisational upheavals. But

whatever the background ethos that led to the lack of collaborative networks

in some of our sites, and from whichever side the relationships’ failures

stemmed, the consequence was always detrimental to the TC as an

organisational innovation.

6.4.3 Marketing to potential users

Finally, in terms of external relationships, several interviewees (both external

and internal to the TCs) emphasised the need to pay greater attention to

marketing in order to ensure that PCTs, non-host trusts, GPs and the local

population knew enough about the TC to want to select it as a preferred

provider.

I think there’s going to have to be a lot of training and working with the GPs to

actually encourage them to start thinking a bit more widely as to where patients

may want to go, and if patients actually do want more information it can be

offered, and that it’s offered to patients in a way that they can actually

understand and access as well.

(Site F: SHA senior manager)

Such marketing activity was unusual for those used to working within the

NHS:

What’s been alien to me is, and I’ve worked in the NHS before, that coming here

you’re working for the NHS but you’ve also got to go out there and vie for

patients. You’re competing with other hospitals for patients which in a way is

like a private hospital as well which is not something I’d heard about, coming

here, and that I’d ever have to do.



(Site A: manager)

In the main, apart from follow up questionnaires to patients who had already

been to the TC, such marketing publicity was carried out using relatively

standard leaflets and websites, with little if any follow up to see how effective

these were. Nonetheless considerable store was set by these activities, and in

Sites A and D this was linked also to their own outcomes research:

When we go to the battleground of the GPs they’re going to want to know ‘if I

send my patients to you what’s going to happen to them?… if I go to them and I

say, ‘well here are the outcome studies from seven thousand patients and these

are our results’, and that will tie in with the new database that’s coming on line

in the next few weeks, and that being our patient satisfaction service. Now, we

used to do it on Excel but it’s very difficult to show the trends of the way things

go and, you know… I mean I can still say, because we know because we still

put them into Excel, that 95 per cent of patients still say that they’ve found that

the service of the hospital are either excellent or good. So we can still say that

but if we can then map that alongside excellent outcome studies then we’ve put

the shebang together in terms of the marketing too.

(Site A: manager)

Site C was perhaps a little more innovative in developing its marketing and

patient information, part of which was based round a custom-designed

cartoon leaflet which subsequently won a national NHS communications

award. In addition to conventional ways of raising its profile, such as a TC

website run by one of the operational managers, Site C developed some

imaginative marketing strategies, for instance setting up a market stall in a

nearby shopping precinct, a strategy also used by Site E. Some of the sites

were also able to use their ‘topping out’ ceremony prior to opening or the

opening itself to market their facilities – often by engaging a celebrity,

politician or member of the Royal family to open the centre, and this (as ever

with such events) was often reported favourably in the local media.

Some fundamental questions arose about the way the public and their GPs

might respond to the opportunity to travel to a distant hospital in order to get

earlier treatment. The assumption that lay behind the government’s Patient

Choice initiative was that they would choose to do so and become more

peripatetic. Yet at least one of our TCs and its SHA believed this to be a false

assumption that had undermined the TC:

The biggest lesson we learnt is that it’s very difficult to move patients around.

Unless you set up a mechanism to direct patients, to signpost patients, to this

alternative hospital, it’s very, very difficult for patients. Because patients don’t

know, and why should they know because they’re like my mother, she never

wanted to know anything about her operation. She said, the doctors know best,

I go and see my GP and my GP knows best, so my GP’s going to send me to the

best place.


And what events have proved, I guess, is that it’s actually more difficult to shift

patients around the system than people thought, and patients on waiting lists

are quite resistant to the thought of transferring from one hospital waiting list to

another one. And one can think of the reasons for that. If you’ve established a

relationship with a doctor and seen a doctor in outpatients and gone onto a

waiting list, the thought of transferring to another hospital and having another

relationship with another doctor isn’t necessarily particularly appealing. And, of

course, for the institutions themselves who have got patients on waiting lists,

it’s not necessarily in their interests to give up patients because there are some

chief executives who call their waiting lists forward order books. And if you



think about it in those terms, it’s the stock of work and the stock of income

which comes in. So I’m not sure there’s been a huge amount of enthusiasm

within the service to transfer patients around because it’s not particularly in

people’s interests and it’s not until you get onto the next stage of choice at the

point of referral that some of those sticky bits within the system actually get

addressed … obviously there’s a relationship with the GP and what the GPs

think about where people should go, and whether they should break tradition or

go with the pattern.


Another manager in the same SHA claimed that only 12 patients out of the

waiting list of 2000 said they would actually go to another provider, which

seemed to substantiate this view of market resistance. Yet figures from the

local Patient Choice scheme claimed that out of nearly 20,000 patients who

had been offered choice, over 60 per cent had accepted the offer to go further

afield for treatment. Elsewhere, some TCs – Sites C, E and G for example,

and for a short period Site A – did improve their chances of survival by

successfully bringing patients from very long distances, and were basing their

futures on their ability to continue to do so. Indeed, Site E attracted patients

from afar despite fierce competition from nearby independent sector TCs and

newly-developing NHS facilities. (It should be remembered that NHS Elect

was founded largely upon the principle that patients would travel for

treatment - see Section 5.) An internal report at Site A stated that there

simply were not enough suitable patients in the area to make the TC viable

without going much further afield to attract patients. They tried to import

patients from other parts of the country with mixed success, and the numbers

steadily increased but still fell far short of what was needed for financial

viability.

One of our case studies, conversely, was basing its plans for a controversially

large TC on the assumption that because of the local population’s fierce local

loyalties and low incomes, patients in its area, even if given a choice, would

much rather stay there even if they faced longer waiting times.

It is surprising that with such glaringly contradictory ‘evidence’, TCs (or the

Government for that matter) did not do more to test the real potential for the

movement of patients. After all, that was a fundamental assumption upon

which much of the Government’s model of commissioning was based. Or

perhaps that was precisely why the TCs were disinclined to investigate it.

6.5 Internal relationships

6.5.1 Recruiting key clinicians

Another aspect of marketing was the need to attract good staff to the work in

the TC.

It isn’t just competition for patients either, it’s competition for staff. It’s

competition for skilled staff and [as a way to attract them] the facilities count

immensely.


Part of their architectural and technological design task for this TC, this

manager told us, was therefore to make it a really exciting and attractive

place to work: to sell the innovative ways of working, the up-to-date



equipment, the modern surroundings. Other TCs had experience of similar

strategies:

There are one or two [nurses] who are going to have difficulties in terms of

childcare and travel, and what [M] is doing is she’s working through it with

them because they’re much more biddable than the doctors and they’re trying

to identify ways of being more flexible... There are some issues there with the

nursing staff, but they’re not as big as the issues with the medical staff, and I

think there is a degree of enthusiasm with the nurses. That’s going to be their

new home and they’ve been involved in the colour scheme. I think there is a lot

more ownership with them… The staff, the nurses that I talked to weeks ago,

they all chose to work in [the non-TC hospital], they live in [there]. Some of them

are going to have problems with transport, but they went [to the TC] to have a

look and were absolutely… it does look good, it looks great, and they went

into… and they said, look we’ve got windows we’ve got daylight you know,

they’re working in inside rooms at the moment and there’s so much space, and

oh the patients will love this. It was all positive and I was delighted about that

because their people are going to be there every day, they’re going to have to

travel there every day. They managed see the benefits of it but the doctors

haven’t.


Although such a strategy proved effective in attracting key nursing staff who

might otherwise have stayed away, the reluctance of the doctors to travel the

20 miles from one hospital to another remained a thorn in the side of this TC.

Things were different at Site E; after some initial misgivings, surgeons and

anaesthetists from nearby hospitals began to see the attractions of doing

sessions at the TC. This required a good deal of dedicated networking from a

manager seconded from a nearby trust, whose key job was to increase

activity at Site E, but may also have been helped by the local politics being so

strongly in favour of the survival of the TC hospital site. At Site H, there was

rivalry between the two sites on which the acute host trust was based and

some strong initial resistance to the necessary travel that sessions at the TC

entailed. Again this required a good deal of ‘selling’ by the TC senior staff:

I’m already aware of heels digging in the sand to say, we are [Hospital 1]

based, we can’t possibly go to [Hospital 2: the TC site] because we’re very busy

people, and heels are dragging along the lines of, we would really prefer to

have our endoscopy services all in [Hospital 1] and not have them part of this

nice new endoscopy service. We’re just working quietly subtly along the lines of

digging our heels out of the sand at the moment. Like so many things in the

NHS, it depends on a bit of mutual back scratching and A being kind to B and B

being kind to A in return, you know.

(Site H: senior clinical manager)

They succeeded with some groups of surgeons, but some key specialties

refused, citing not only the inefficiency of the travel, but arguments about

clinical safety that were not entirely convincing. The TC had to accept, despite

all the efforts of the senior clinical managers, that some surgeons would

simply not move to the TC hospital site, and that their specialist registrars

would work there instead. As a final example, a board meeting at Site D

reviewed the internal reasons for its predicament and cited six main causes,

of which three were connected with a failure to find staff who would be willing

and able to undertake the new kinds of work expected.

At Site D attempts to recruit key staff were further complicated by the human

resources (HR) procedures and policies of the host trust. Site D was wanting



to recruit into innovative roles, such as advanced nurse practitioners but the

trust’s HR department refused to recognise this role and the TC were forced to

regrade the post according to existing staffing profiles.

Finally, the strategies used to recruit some types of staff could backfire on the

TC’s reputation with others. One site gained a bad name by relying on

existing networks linked to one particular senior manger to build up a clinical

team. As one staff member put it:

One of the real issues was around favouritism. … they were [name]’s buddies,

it’s as simple as that. And they weren’t all from here, not at all. A large number

of them were from [another hospital]. So if you weren’t chosen to go down there,

you knew that you weren’t one of the guys who were going places

(Manager)

As all these examples show, it was not easy to staff TCs, which was obviously

a problem in establishing this NHS organisational innovation. Apart from

needing to work hard to persuade key professionals to come and work in the

TCs, the innovation also depended on persuading existing clinicians and wider

trust organisation to adopt and to help develop – rather than oppose – the

innovative ways of working that it entailed. We return to this point in Section

7.

6.5.2 Retaining managers

Another need was for good project management to see the innovation

through its various stages from planning, recruiting and training staff,

marketing the new service, to dealing with all the setbacks and so on.

Unfortunately the turnover of senior project managers was itself one of the

setbacks that undermined a number of the TCs. At Site F, to take an extreme

example, there were four changes of project lead between the opening and

eventual closure of the TC – and usually because the person concerned made

a career move upwards on the basis of their contribution to the TC. This

turnover was widely seen as a factor that contributed to the ultimate failure

(that is, closure) of the TC at this site not only because it led to internal

delays in setting up basic systems within the TC, but also because the

constant changes of personnel meant that external links and relationships

were never properly established. Moreover – as we saw in Section 3 – the

senior executives of the host trust did not sustain their interest in the project,

but soon moved on to other priorities, leaving a series of TC managers to

grapple with the major problems that were now besetting the innovation:

I was asked to be involved but it’s been a messy process. It’s been an

incredibly messy process. We’ve had four general managers already. We had

two periods without a general manager. We never had clarity, right from the

beginning, as to the financial streams. So, I’d refused to begin with. I was

asked and I said, no, not until I get the appointment of a manager. We were left

in a position where the whole thing was up and running and just as it started

the GM in place was… basically going to walk away.

(Site F: senior clinical manager 1)

I remember a period when we would ring up [Site F], because I was just about to

go down there and explode one day because things were going so badly wrong,

and we rung up three times in the previous three weeks and got a different

administrator each time who was running it. It does not work.

(Site F: senior clinical manager 2)



At the other end of the spectrum, Site B, which steadily increased its activity,

efficiency, influence and impact on the improvement to the hospital’s

performance figures, had no significant staff changes in the management

over the three years of our fieldwork. At Site E there were three changes of

chief executive of the trust, which was in chronic financial difficulty, but there

was one TC project manager throughout who retained the authority to take

charge of the entire setting up and running of the TC. This to a large extent

protected the TC from the financial problems of the host trust. When the

project lead finally left (as a positive career move) the trust took the

opportunity to reduce the relative independence of the TC (see below) by

splitting his job into two. One manager was appointed, as it were from the

host trust, and one from within the TC. This allowed both continuity and

realignment, and averted any potential setback caused by the departure of

the person around whom the success of the innovation had revolved.

At Site D the original TC chief executive (who saw himself and the TC as

being separate from the ‘host’ trust) left his post in 2004 and was replaced by

a general manager who now reports to the ‘host’ trust chief executive

(originally the TC manager had been reporting to a board made up of

stakeholders from across the local sector). The fact that the new TC manager

was not designated as the ‘chief executive’ of the TC did not go unnoticed:

one middle manager within the TC commented that as soon as the post was

advertised as a general manager ‘we lose our identity… It makes it harder to

win but doesn’t mean we are not winning’ At Site C the TC project lead, who

had been seconded to oversee the build and operationalisation of the TC took

a promotion which moved him out of the trust shortly before the TC opened.

The departure of this person marked a similar re-absorption of the TC into the

host trust, as the chief executive took on much of the oversight of the final

decision making in the run up to opening, and the day to day responsibility

passed to a more junior, home grown general manager with a nursing

background.

Similarly, at Site A the initial ‘entrepreneurial license’ has now been revoked

and the role of the TC is being continually revised (exemplified by the

departure of the first hospital manager and the clinical director), accompanied

by closer management of the TC from the ‘host’ trust. The original hospital

manager was seen as the:

…right person at the right time. We now need someone different. We’ve just had

an ‘Investors in People’ report down there and it was just amazing: it waxed

lyrical about his leadership style. He was absolutely the right person at the

right time, his background is in the private sector. He’s jolly, and a good

communicator and a little bit anarchic. In terms of the set up [hospital manager]

was a deliverer, it would open when he said it would open and he would get the

patient’s through the door but given the fact that they started from scratch he

did a very good job…but at a cost… He’s another Machiavellian but very

successful but now we need to consolidate.


At Site H the original TC manager also left after two years in post and a

newly-appointed ‘service improvement’ senior manager at the host trust took

on the TC-lead. Responsibility for the TC then lay with one of seven directors

reporting to the chief executive at the ‘host’ trust. At Site G the chief

executive and the director of finance who had instigated the idea of having a

TC had both left by 2004. The incoming chief executive had experience of



championing a TC at a previous site, but perhaps more importantly had a

clear vision of where the trust as a whole should be headed and appeared to

communicate this effectively to staff at all levels across the trust.

Interestingly the chief executive appointment was made after a series of

other key appointments to what was in effect a whole new tier of middle

management at the previously under-managed trust. Significantly two of

these new managers, both directly involved in the development of the TC,

came from outside the trust (and geographical area) and brought with them

what can be described as a ‘business’ ethos, which defined the mission as

making the TC (and the activities of the trust) profitable and competitive.

6.5.3 Other relationships and systems

Finally in terms of internal relationships it should not be forgotten that other

agencies such as architects, builders, supply companies, and hospital support

services such as central sterile supplies departments all needed to play their

parts as agreed, and when they failed to do so, the innovation could and did

suffer setbacks. Alongside these relationships other factors, notably

construction problems at the new-build sites and failures in electrical and

telephony services, provided further hiccups in the developmental career of

the TCs. One difficulty encountered by five of the case study TCs was with the

information systems upon which modernised care was expected to rely.

Site H had planned to use a computerised scheduling system in the TC but

there were problems and delays with this, particularly in relation to the

interface with trust-wide and national systems. They had therefore made little

progress so far with scheduling TC work. Here there was no sense of

innovation being led by information technology (IT), rather, traditional

process redesign would lead any IT developments:

IT isn’t valued very highly in this trust… I think the innovation will come from

lots of the process redesign and then IT and information will be applied to that

afterwards, rather than IT and information supporting the process redesign.

We’ve got so many manual processes within the trust, whether good or bad.

The process redesign will hit on the manual processes and then they’ll try and

fit the IT to that, and then it’s the usual case of well, if you’ve got a bad

process, no matter how you put IT into it, it doesn’t improve the process, it just

makes the process go quicker. So, the innovation I think will be there, but

because of the IT value, I haven’t necessarily been involved in that. So for the

scheduling, it’s a case of if there’s scheduling software out there can we do

anything with it? Well no, there isn’t at the moment, we’ll wait for the national

programme, okay, we’ll leave it. So there may be innovation going on, but from

IMT not very much involvement.

(Site H: manager)

Also in development at Site H was an innovative computerised information

system for following up and monitoring patients in outpatients, which aspired

to provide more concrete data on the success of the treatment (partly as a

way to persuade commissioners of the benefits of using the TC – see earlier

comments regarding ‘marketing’), but at the time of writing this had still not

materialised.

I mean the notion was, and my vision is, that we have a system where patients

are wholly electronically booked into the system where their pathways are

electronically controlled and followed through… So I had a view that for

endoscopy for instance you go for your scope and your records are on screen



and the minute you’ve had your scope the clinician can do drop down things to

say I’ve done an OP GI [outpatient gastro-intestinal] examination and I found

nothing, blah, blah, blah, and that automatically then, even before you’ve got

back into the lounge to sit down, is on the GP’s system in the notes printed off

so you can take a copy home with you. That sort of electronic system, and the

results, can then be used to – again, before you go home – plan any further

elements of care. So you can schedule and book all of those as well. Now, I

think that’s how a treatment centre should work. The technology hasn’t caught

up. So we’re going to open a TC using old technology and then find it very

difficult to implement new technology. It’s always better when you’re opening a

brand spanking new thing like this, you might as well do the whole thing at

once because people will accept it. It will be much harder to get them to change

after. So that I think is a bit of a sadness that we’ve not quite got there because

of the technology.


Site F also ran into various IT difficulties but, typically, saw the blame as

resting with the other organisations with which the TC interacted.

The performance manager just sits at a computer day-in-day-out taking phone

calls from…. [Patient Choice] and from our buddy hospitals and just putting

them on a spread sheet. And even then if you were to ask him the question,

how many people have you seen under [Patient Choice] or under our buddy

system, he couldn’t actually tell you without pulling out loads of spreadsheets

and manually counting them up.


I guess the other problem we’ve had which is worth mentioning is the

organisation of some of this Patient Choice stuff has been lamentable and has

caused difficulties for referring hospitals. For example, if I was to say to

[Hospital X] you must transfer more ENT [ear, nose and throat] patients to

[Patient Choice] they would say ‘that’s all jolly good but can you tell me what’s

happened to the patients that we did refer because we’ve not got any

information about those’.


At Site E there was a problem of incompatibility between the existing digital

imaging service and the system to be installed in the new (stand-alone)

hospital site. This delayed progress for a while and ultimately required a

different – and more expensive – technical solution. Despite talk of electronic

records and digital imaging, Site G also encountered significant problems,

notably in processing patients from outside the trust catchment area. Here,

there were apocryphal tales of patient notes and X-rays being couriered by

taxi ‘in carrier bags’ from far distant trusts. Likewise at Site A the information

systems were simply not geared up to support the TC activity:

I think that’s, again, one of the biggest problems that we’ve had from the

beginning, is that the hospital PAS system, or whatever you want to call it, is

not really set up to deal with varying trusts sending their patients and then us

giving them information back as to what’s happened to them in as much as

information that they can then confidently take the next step with whatever

they have to do with their patients. So what we do instead is we use the PAS

[patient administration] system just because we have to but we use

spreadsheets, so we’ve got this terrible situation we’ve had for a year of

balancing patients with two systems so that the quality of the data being put in

is questionable when you’ve got two systems going on and we’re managing

patient information with spreadsheets. It’s quite frustrating because, again, it’s

one of those things that you recognise right from the beginning that unless you



really have a good information system being able to examine your processes

and things you need to be able to vary the type of information you want to get.


And at Site C, despite it being an ultra-modern new build, we found that

theatre scheduling lists were still being prepared manually, aided by a variety

of ad hoc individually developed software solutions:

On the information side I collect and collate all the data and it’s on an in-house

theatre system that we’ve had running now for 14 years, which originally was

only supposed to act us for two years. So it’s a manual system so all the data

that we collect has got to be coded manually and printed.

(Site C: manager)

These examples highlight how local technical or financial detail could shape or

alter the organisational innovation that was eventually put in place. An

innovation as complex as a TC, relying on a wide range of key actors could

only be expected to survive if active steps were taken to ensure that all the

relevant factors were properly in place. This was by no means always

successfully accomplished.

6.5.4 The parent trust

TCs had to establish themselves as distinct and reputable entities not only

with potential commissioners, patients and the higher echelons of the NHS

and Department of Health – as well as their own staff – but also with the host

trust. We saw in Section 3 that the TC was often expected to solve the

problems of the host trust. To what extent did they manage to do that and

how did the relationships with hosts develop? It was difficult to avoid an

analogy between the relationship of the TC with the trust and that between a

recently matured offspring and its parents. There were inter-related tensions

over:

• autonomy – the freedom to act independently from the parent

• finance – arguments over money

• help with the ‘family business’

• conflicting attitudes or ethos between parent and offspring

• pride in achievements that reflect well upon the parent versus concern

about failures that backfire on them.

The tensions depended partly upon the character and standing of the ‘parent’,

partly upon the actions of the innovative offspring, and partly upon the

material circumstances in which they both found themselves. These scenarios

played out in a variety of ways.

Site E gradually increased its independence from the parent trust. The

manager of the TC sat on the trust board, (thus strengthening the links and

visibility between the two), but the TC had its own clinical board and other

structures that confirmed this semi-autonomous nature rather than being

fully integrated within the trust. Staff, despite having their day-to-day work

managed in the TC, were also managed by others, at a distance, in the host

trust (for example the trust’s director of nursing had overall responsibility for

nursing staff in the TC but oversight of the specific practices employed in the

TC were delegated to the nurse managers there.) Once operational, the TC

had little contact with the host trust, save through the surgeons who operated



in the TC and were based in one or other of the trust’s acute hospitals, and

the chief executive’s regular visits, which he told us were designed to show

that people working in the TC should feel part of the wider trust. In general

this degree of separateness was clear, but in the early stages there was some

confusion not least as regards responsibility for the clinical governance of a

facility that did things very differently from the rest of the trust:

That does pose challenges in a lot of ways because, whereas some of the other

facilitators are responsible across the trust, I am based at the treatment centre

and a lot of the services provided within the treatment centre falls under the

management on a wider trust-wide basis. That can be quite tricky, really... So,

that does pose complications at times because I can’t just go off and put things

in place for one area without taking into account whether it’s appropriate. For

some things it is appropriate for [Site E] and the treatment centre to stand alone.

We don’t want to stand in the way of innovation because it is an opportunity to

be forward-thinking and do things differently… It does [feel like an organisation

by itself]. It does a little bit. I think in a way that that was bound to happen. I

think it’s still all clear. I think there’s been confusion over clarity roles, really.

Are they being managed by the general manager here or are they managed by

the head of radiology? And that is quite difficult. I’m not sure the trust has got

to grips with that yet. They’re just evolving as things come up and that has been

an issue with governance.


Such uncertainty was quite common among sites where there was a degree of

autonomy; the desire for entrepreneurial freedom fitted ill with the need for

bureaucratic control of publicly funded services. Not only was there a question

about accountability for public funds, but also for clinical governance. If the

TC was allowed full autonomy, then were they also responsible if there was

an untoward clinical event? Or would the trust be held responsible, in which

case could the trust justifiably insist upon keeping some control?

The fact that it was unclear as to what happened to a patient if say the patient

had a myocardial infarction, where the on-call team was, what the processes

were, was something which was highlighted pretty early on. And I think there

was a divergence of view… the PCT view was that what was required was

clear, unequivocal governance in terms of who was responsible for what…

which is what we have now. So I think it all started because there were

questions raised. There were a few questions raised also about drug

treatment…. They could order how they liked. The difficulty was… that’s fine

as long as there were proper governance arrangements, which there weren’t,

and as long as there was clear financial control, which there wasn’t.

(Site D: PCT senior medical manager)

You have the chief executives of each of the base hospitals on a board, together

with other representatives, PCTs and whatever. But then that became difficult.

Again, in terms of fixing it within governance arrangements – the existing

governance arrangements in the NHS – I know… this is even a thing I discussed

with [K] – his view is very firmly – yeah, he wants somewhere where the buck

stops and actually having it under [host trust], at least we know where the buck

stops. It was an interesting debate at the [host trust’s] board meeting, where

there are non-execs… who have not been involved in the process to date. We’re

actually very resistant to this idea, because they wanted a lot of reassurance

that the risk… that they weren’t actually taking all the risk of the centre on. And

the finance director of [host trust] tried to reassure them that, actually, although

the governance fits with [host trust], the buck stops there in that sense – but

there were very firm risk-sharing protocols that new people have to sign up to.

I’m not sure they were totally reassured by that.

(Site D: patient representative)



After all the key local ‘champions’ had moved on, Site D complained of having

to re-sell the TC concept all over again to the new chief executives of the

partner trusts and of ‘a difficult first meeting’ with them. Although the TC had

been planned since the late 1990s, as late as March 2004 one partner trust

refused to approve proposed governance arrangements. It:

…expressed concerns with regards to ‘accountability’ and why the centre was

not simply a division of [host trust] with service level agreements with the other

base hospitals… specifically asked about the role of executive directors, the

lack of non-executives, the patient forum, the relationship with the Commission

for Health Improvement and the patient involvement processes… The trust

board concluded that is was unable to approve governance arrangements

without further clarification of the issues raised.

(Site D: trust board minutes [host trust])

Eventually these discussions led to the increasing reintegration of the TC with

the parent trust (and the replacement of the TC chief executive with a general

manager – see Section 6.5.2), along with ‘options for reducing the cost of

providing the service [which] should be pursued aggressively’. The TC had

been brought back into line with usual NHS governance arrangements with a

shift to single managerial and financial accountability through one ‘parent’

organisation. A similar shift occurred at all the TCs, where the tensions of

autonomy versus accountability became a concern.

In Site A the original TC manager reported directly to the chief executive at

the parent trust, which caused some difficulties:

He had a direct line into [chief executive of host trust]. For a while I wasn’t

involved at all in this process and [the TC manager] related directly to [chief

executive of host trust] ... bit of a favoured child kind of syndrome and the

others did think, ‘there are no laws, he can do whatever he wants to do’ and

they were jealous.


With the departure of the original TC manager and the clinical director, the TC

became much more closely integrated with the parent trust:

Now we have [the chief of orthopaedics at the parent trust] sits on the clinical

board down there and it is much more of a symbiotic relationship. The waiting

list is now managed by [Site A] but there are decisions at pre-assessment that

this patient needs to be seen at [hospital X], this patient can be managed here

at [Site A]. It’s a move from being stand-alone to – I wouldn’t say integrated

quite yet – but there is a clear pathway and it is seen as much more clearly

defined across the two.


This is reflected in the new management structure around Site A:

We now have an operation executive [ops exec] that I head up. It’s much

broader base than it was: we have finance in there, acting head nurse,

development director, general manager, clinical director, and a representative

from the complex centre at [hospital Y]… and then we have the [TC] board which

is a stakeholder group with representative. The ops exec was missing… there

was nothing that was driving the business side of things and that’s where the

ops exec comes in. Then the [TC manager] has a senior management group that

sits under that.




Thus – at Site A – the increasingly daunting financial liability arising from the

failure to carry out the expected activity meant inevitably that the host trust

reasserted control over what had been intended as a virtually autonomous

TC. There was a period of somewhat poor relationships and muddled

responsibilities, but within two years the TC’s original ‘entrepreneurial licence’

had been, as it were, revoked. This reintegration into the parent organisation

had clear implications for the TC:

…[before] it was very much an independent republic and [now] it is much more

seen as a divisional directive which has both strengths and weaknesses,

strength in terms of corporate information … We’re much clearer about what’s

going on there and we get the activity reporting and financial reporting, one of

those things is about the way that we do business, the information that we use

in terms of quality here. The downside is that it is now being perceived as just

another division of [the parent trust] and clearly that is not the case.

(Site A: senior manger)

Inevitably the host trust reasserted control over what had been intended as a

virtually autonomous TC.

You have to think of it like a business, you know, no business can survive if we

have another year where we lose the kind of money that we’re projected to lose

this year. We’ve got a deficit of millions and millions of pounds, and the only

way that we can break even, is if this place is full. Partly it’s because we’ve got

a very expensive lease on the building, we don’t own this building, we lease it,

and even if we lock the doors, redeploy all the staff and have not another

patient in here for the next seven years, it will cost... because of the overheads

and the leasing, and whatever. So, that’s madness, so you’ve got to fill it, and I

think they’re right to bang-on about it, because, as you say, I think it is this

conflict of policy. The government has set these policies, and I can see the

sense in setting them, but they clash regularly, and something’s going to have

to give.


Despite increased referrals as some of the local trusts softened their view in

the light of positive experience from their surgeon who carried out sessions at

Site A, the situation continued to look bleak. At the time of writing, the host

trust was still desperately trying to persuade the SHA to step in and convince

local PCTs to send patients to the TC, but sale to, or partnership with, the

private sector was being increasingly considered as the most likely option.

In contrast to Site A, from the very beginning at Site H the TC was clearly

going to be an integral part of the host trust:

It’s part of the trust services and governance will be dealt with in exactly the

same way as it is now and for the rest of the trust. But I think you’re right,

certainly when we dealt with the overseas clinical team up here we had

massive discussions about how we would… issues about responsibility for

clinical governance and how that responsibility is exercised and assurance

given around clinical governance matters, and we set up the scheme upstairs

for instance, which is more akin to a stand-alone treatment centre. We had to

set up specific systems and processes to make sure we had all that in place,

and that worked pretty well. But our treatment centre will be an integral part of

the trust services, so it’s our existing clinical governance arrangements.


It seems to have been relatively on line in timescale. In fact, it has come on line

early, which is quite remarkable, I think. Naturally, when you start looking at

the treatment things, it seems as though it is fairly integrated within the ethos



of the trust. It isn’t some sort of little development that’s sitting outwith, which is

what happens with a lot of them. It’s like something that’s going on in a

cupboard that isn’t necessarily integrated with the whole of the trust strategy,

whereas I think within [the parent trust], it is seen very much as helping to

deliver some of the strategic reconfigurations that have been going on.

(Site H: senior manager SHA)

While Sites B and H had always intended to be integrated with their parent

trusts, it is striking that in all of the other case study sites that had intended

greater autonomy, the trend was inexorably towards normalisation and

increased re-absorption into the ‘usual way of doing things’ in the NHS.

So it was at Site E, where, after the departure of the visionary project leader,

the management was restructured and the TC was drawn back into the host

trust.

So basically the director of operations is responsible for all hospitals now. And

actually that has brought us in from the cold, so to speak, to be much more part

of the trust.

Interviewer: Is that good?

I think it’s good and it’s bad. It depends on which route the trust wants to go

with the treatment centre. If you want to use it as part of your current capacity

to manage your patients out in trust, it’s got to be good because you can only

then improve the way you are using the treatment centre. If you want the

treatment centre to be money earning, go out there, have separate waits, that

sort of marketing aspect, then it’s difficult to do that because what you’ve got to

still then do is use the capacity that the trust doesn’t need and the trust doesn’t

want to turn around and say that capacity is not needed

(Site E: middle manager)

Site C (reflecting its origins as an ‘opportunity’ to expand the new hospital)

experienced a continuing tension between being a separate entity or an

extension of the hospital. As the financial pressures caused by the loss of

anticipated activity hit home, the scaled down TC became more and more

integral to the hospital, with few lingering signs of any particular innovations.

But in Site E (as in others such as Site B which was integral with its trust

from the very start) the reintegration of the TC into the main hospital had the

advantage of making the benefits of the new ways of working more widely

visible, and thus helping to spread their adoption:

A good practice thing that I very quickly picked up on when I first went to look

at their day case area, and also for the inpatients, a small amount of inpatient

activity that’s going on out there, all their patients get a follow up phone call.

That is excellent and it’s something I’m thinking we [surgical directorate at

another part of trust] should be doing.

(Site E: senior clinical manager, host trust)

The TC managers at Site G were struggling from a very early stage to

persuade the host trust to ring-fence the planned-care beds. Although the

trust did agree to this in principle, the high level of emergency admissions

meant that they could not afford to ring-fence the TC beds. Here the TC had

been the beneficiary rather than the leader of a flowering of innovations in

care pathways across the trust, and it soon became subsumed in a much

larger section of the hospital devoted to planned care being carried out

according to the new patient pathways. However, even that vision was

difficult to sustain as emergency care often took priority (and beds): ‘So



basically,’ as one senior manager described it, because of the overwhelming

problems of the host trust, the TC’s ‘planned care has gone to pot’.

The danger of a TC’s ideals being buried by the bigger problems facing the

host trust was not lost on those trying to establish Site H, and their solution

was to try as far as possible to keep themselves out of view, as it were, from

the quarrelling parents:

I think the way it’s being presented is that this is being presented more as a

reorganisation of existing services [rather than as organisational innovation]. It’s

a reconfiguration of existing services which enables an extension of service in

effect, both in volume and in opportunities for some innovative working… you

may have picked up that there are significant local political difficulties around

[the TC development] So, how things are put across is very delicate ... So, I

think if the TC was on its own without all this political shenanigans around it, it

will be far easier to package… What we’re trying to do is develop this and

deliver a service change without it becoming contaminated by the other politics

and equally without it raising the stakes of the other politics as well. So, to

some extent, it’s quieter than it would otherwise be because of that I think.


But this did not allow them to gain the autonomy they were hoping for. The

even more pressing problem was the deficit of several million pounds that

developed in the host trust, which meant that plans to recruit an operational

manager for the TC had to be shelved as funding was removed. But – as the

following example illustrates – the deficit meant that the TC had to ask

permission for many of its essential features, hoping that the outcomes of

subsequent financial negotiations and decisions would be beneficial to the TC:

Basically we did a business case or rather [P] did a business case. He put it to

the trust and they took it to PCT who said, yes, we support this pre-operative

system but we feel that that should come out of your ‘access money’ [funds

ring-fenced by the Department of Health to improve patient access to services].

So in a sense they were giving us the money but they weren’t giving us the

money. But the trust has recognised this will actually… it’s money well spent

because it will reduce the cancellations but even more importantly, really, we’re

giving much better service to the patients


At Sites A, F, and D financial deficits – whether in the parent trust or its TC –

resulted in a loss of autonomy for the TC as an innovation. At Site F, the TC

finally reverted to being a department of the hospital (which helped for the

short period before it closed) and, as the external flow of patients dried to a

trickle, focused on using the increasingly spare capacity to get the host trust’s

waiting lists down. Staff, many of whom had not been committed to the

ideals of the TC anyway, were relatively happy about the TC falling back into

the trust like a wave sinking back into the sea:

At least doing our own patients they were known to the staff and so

consequently they were properly selected, properly investigated.

(Site F: senior medical manager)

At Site D, in contrast to Site F, staff were very unhappy about the host trust

trying to wrest back control of the TC because of its mounting debts. Many

felt that the TC’s ‘vision’ had been gradually eroded by the trust, with the

trust taking more and more control, expressed by one manager as ‘loss of

control over how we can implement change’. The TC staff felt that as a result

they had lost some of their unique identity. Moreover, some TC senior staff



felt that the TC had been doomed from the start because it was born into a

trust that had been struggling to meet the waiting time targets for a long

time: the failure of the TC merely, as it were, symbolised the chronic failure

of its parent trust. (For them, suggestions that the TC might be sold to the

independent sector might not be necessarily unwelcome; they argued in

favour of the private sector ‘to bring diversity and innovation’. Other senior

clinical staff were concerned about ‘selling off the NHS’ and that it was likely

to cause a political furore among the trade unions.) In fact the host trust had

given the TC more latitude for rather longer than the TC’s massive financial

shortfall might otherwise have merited because of the trust’s

acknowledgement that the TC was widely seen as an NHS flagship that would

help to raise the trust’s standing.

However troublesome the environment and whatever problems they ran into,

all eight of the case study TCs had at least some degree of success in helping

their trusts improve their performance against such targets as waiting lists,

as we will see in the next section. But it wasn’t always possible, for example

at Sites A and F, for the trust to acknowledge or celebrate that achievement,

because the TC offspring was also causing the parent serious financial and

other difficulties.

At Site B, it was widely acknowledged that the TC had been essential to

raising the hospital’s profile and local kudos by improving both the quality of

care (new patient pathways and new ways of working) and the quantity of

care (increased throughput). Indeed the new facility was doing much to help

the trust achieve its hitherto elusive performance targets and strengthen the

case for foundation hospital trust status, which was a major goal. But

precisely because the new unit was embedded into the very workings of the

hospital, which was the chief reason for its success, it could not be paraded

as an achievement. There was:

…no glossy building with identifiable presence that a minister can come down

and cut a ribbon on… It has to be glossy and sexy, something you can feel and

hold… The ACAD [Ambulatory Care and Diagnostic Centre] is a wonderful

building, for example which ministers can go to and show off. The same isn't

true of the sort of thing we are developing here. And that presents a

‘presentational problem’.


6.6 Achieving targets

To a large extent a TC’s ability to compete and overcome its problems

depended on the degree of over- or undercapacity in its local health economy.

At one extreme, Sites A, F and D were opened in an environment where there

were simply not enough patients to allow them to compete effectively in an

era of Patient Choice, G-Supp or independent sector TCs, (see Section 5) and

the effects were devastating. At the other end of the spectrum, Site B had a

shortage of capacity and little threat from such policy shifts. Somewhere in

between were Sites C, E, G and H, where a combination of marketing and

collaboration with commissioners and providers of health care allowed a more

or less reasonable throughput of patients even though the original planning

assumptions had proven to be misleading. But despite the mixed motives for

opening the TCs and all the difficulties that emerged once they were running,



most of our case studies were seen to have increased the throughput of

patients and were contributing significantly to reducing waiting times.

For example Site A, for all its difficulties, was nevertheless helping the local

trusts to meet the Government’s stringent waiting list targets. As our

fieldwork was ending, one option appraisal, which included the suggestion

that the unit be closed down, concluded that the TC should be kept open, and

a number of suggestions were made to help limit (and share) the continuing

financial losses. This was based on the view that over the coming two or three

years there would still be a need for at least some of the beds to remain open

in order to continue to meet those targets.

Even Site F, which was eventually forced to close, was able to capitalise on its

unused facilities to make a significant one-off contribution to reducing its host

trust’s waiting list targets. This was probably a temporary benefit of the very

feature of the TC that eventually led to its closure: its ultimately unfillable

spare capacity. Certainly it was not due to its different ways of working, the

average length of stay of patients going through the TC being no different

from the rest of the trust.

In contrast, Site B was struggling with serious undercapacity and the

innovation of the TC was deemed a success from the very start because it

immediately became essential to easing the strain on beds. The TC was thus

allowing the trust to hit many of the targets that it was at last beginning to

achieve, such as increased activity, reduced lengths of stay, fewer cancelled

operations and shorter trolley waits in emergency departments. The

innovation functioned not only as a way of separating elective patients and

shortening their lengths of stay, but also as a capacitor for the surgical

division into which all short stay patients could be placed just as soon as

convenient. Not surprisingly, such a unit was almost never referred to as a

TC. It was led by a dedicated and experienced nursing manager, assisted by a

team of enthusiasts whom he trained to both run the ward and to organise

bed management and theatre lists across the surgical division. By boxing and

coxing with the full complement of beds in this way, the team managed to

achieve over 100 per cent bed occupancy for the whole hospital most of the

time. This entailed a great deal of detailed quotidian activity by the senior

nurses in the team, very tight control of bed usage using easy, friendly,

trusted professional networks across the main wards, and a great deal of tacit

knowledge about surgical procedures, recovery, and individual surgeons'

idiosyncrasies. All the other TCs were also recognised by the wider health

economy as major contributors to achieving not only waiting list targets, but

also providing greater patient choice.

Some TCs also saw the opportunity to work more closely with the private

sector, through schemes – as in Site E – to rent space to independent health

care organisations or even (discussed but not yet agreed at several of our

other sample sites) to develop the TC as an independent sector TC. This had

the potential of allowing those TCs to benefit financially from fulfilling the

government’s targets for up to 15 per cent of all NHS patients to be treated in

the private sector, which their parent trusts saw as an additional benefit.



6.7 The study sites at the completion of fieldwork

This section has related the story of how the eight TCs in our study evolved,

and we hope that in describing what happened to these sites we have

captured the many and various ways in which they implemented this

organisational innovation. We have revealed how all of the TCs were subject

to poor planning assumptions; the individuals trying to put the TC idea into

operation found themselves unable to accurately predict important variables

such as activity and casemix, partly due to poor data and partly because, for

most sites, the timeframe for this planning was highly compressed. We have

also shown that this planning process was highly contingent both on the

shifting ground of the wider policy context (see also Section 5) and the

external and internal milieus (see Section 3). Good relationships with the host

trust and other key partners were also vital to the development of the TCs.

The failures and difficulties encountered by these TCs, and indeed the

variance between the ideal TC espoused in the NHS plan and the actual TCs

that emerged in the eight sites could be seen as a consequence of poor

planning. However we contend that better planning would not necessarily

have ensured that these TCs came closer to the ideal type proposed by

central Government, nor would it have resolved all of the problems detailed

above. Rather, the evolution of the TCs mirrors organisational innovations

generally (Van de Ven, 1999; Greenhalgh et al, 2005; see Section 10). It is a

highly contingent process, dependent on the interactions of context, history

and relationships, often subject to serendipity or chance events, but

nevertheless following a general pattern.

The stories of these eight innovations continue to unfold: here we simply

summarise the state of play when our fieldwork ended. Of the eight case

study sites selected in 2003, one had closed by 2006, three were examining

or had entered into agreements to selling space and/or capacity to the

independent sector and one had been bought out by a private health care

provider. Three sites remained (partially) identified with the NHS treatment

centre programme. Two of these were, initially at least, relatively small scale

initiatives. By 2006 one of these was subsumed into to larger organisational

project around planned care, but nonetheless was still attempting to practise

the aims and ideals of TC brief (by separating elective and emergency care,

increasing activity and improving patient experience) albeit in highly

constrained financial circumstances. The other had effectively been absorbed

into the host trust while still successfully developing ‘new ways of working’,

but the host retained the ambition, albeit currently threatened, of opening a

much larger, separate TC. Only one of the eight sites appeared to have

weathered the storm, emerging as a stand-alone TC that largely mimicked

the early Ambulatory Care and Diagnostic Centre and exemplified key

elements of the policy model of what an NHS TC should be.

The fact that so few of our case studies managed to create and sustain the

innovation exactly as envisaged by central Government does not necessarily

mean that they were unsuccessful. As we have shown, all the sites were able

to contribute to increased activity and throughput and to the reduction in

waiting times. Indeed the number of patients on waiting lists had fallen by

400,000 and by 2005 was below 800,000 for the first time since records



began (Department of Health, 2006c). In addition, as the next section will

show, many of the sites were also innovative in developing new ways of

working that led to improved practice.



Section 7 Improving practice? Evidence of innovation and new ways of working

Whatever the broader issues that were challenging the longer-term survival

of the TCs (Section 6), all of the TCs in our sample had – more or less

explicitly – a group of enthusiasts who generated the momentum and the

energy to try to bring about the necessary innovations and improvements in

care, based on the motivations we have described in Section 4. For them, the

strategic aims of meeting government targets were secondary. In this section

we focus on the ways in which innovations in care were actually achieved,

including changes in both the structure (such as transformations in the

physical environment and in staffing) and the process of care (such as the

application of new clinical pathways).

7.1 Changing practice

It will come as no surprise that those responsible for developing the TCs

needed to invest a good deal of effort in persuading senior staff – especially

hospital consultants – to engage with the new ways of working. We referred

earlier to the importance of ‘idealists’ in the development of the TCs, and all

the sites had such people whose main motivation was to improve – even to

transform – the patient experience. It was not possible to discern any pattern

across the sample that any particular professional group such as managers,

doctors, nurses or other clinicians had a preponderance of idealists. Each

profession had its share of sceptics, pragmatists, opportunists and idealists.

For example, although sceptical hospital consultants were often a challenge to

be overcome, many of the enthusiasts leading the change were themselves

consultants. To a less visible extent, this was also true of nurses and other

clinicians and managers.

Success or failure in that improvement endeavour was dependent upon the

teams’ abilities to make use of the usual features of good change

management in clinical systems including:

• appropriate use of personal networks among colleagues where there was

mutual trust and respect

• harnessing opinion leaders, especially senior respected clinicians

• learning from and building on the experience of success locally and

elsewhere

• understanding and thinking through the motivators and barriers among

key staff, and working specifically to deal with those

• timing interactions carefully to optimise the chances of persuasion

• empowering staff who were already keen to change (novitiate idealists)

• introducing a management framework (for example a modernisation

lead) and structure to facilitate change.

As an example, the group of enthusiasts at Site B steadily overcame the

scepticism among the consultant body by the skilful deployment of strategies

and activities such as those listed above. The TC team there achieved what



were, for them, considerable innovations in the way clinicians practised, such

as new booking systems and alterations to a wide range of clinical processes,

which were the key to improving the hospital’s performance. This happened

largely because a small group of like-minded innovators were trying to

redesign the way things were done and were using the TC as a vehicle for

driving forward this campaign of change. They did this through informal

encouragement and example but also through formal methods such as

‘process mapping’, exercises in which they tried to include clinical opinion

leaders. The group was supported by being given organisational space and

encouragement (but little resource) by senior management. But mainly the

group relied upon the use of subtle techniques, building on its internal

networks and gradually pulling in more of the senior doctors as allies, to

create a groundswell for change. They succeeded partly because the

hospital’s performance targets and problems demanded it, partly because

they were enthusiasts who want to improve things for patients and staff, and

only coincidentally because of the TC. However the new patient pathways that

emerged from this process were also an essential part of the planning for the

second phase, new build TC.

Clinical opinion leaders, who played such a pivotal role at Site B, were an

important factor at all the sites. When opinion leaders maintained their

scepticism, such as at Site F, where even senior medical managers who were

expected to help lead the change were thought to be against the TC, there

was little change: most doctors continued to feel threatened, unenthusiastic

or even resistant to the TC.

At Site E, opinion even among senior clinicians was provided largely by a

project lead whose vision of the new TC commanded their respect. This vision

was based on previous successful experience of using patient pathways which

matched the opinions and aspirations of the local clinicians. Site E seemed to

have little trouble in persuading clinicians, including senior surgeons, to adopt

the new protocols and pathways that had been developed. There seemed to

be three reasons for this. First there was strong enthusiasm to make the TC a

success, a desire almost to prove the point that the TC would both replace

and surpass the recently closed and much mourned hospital. Clinicians were

fully committed to this idea. Second, the vision of the TC manager was

respected and shared because of his experience in a renowned centre

elsewhere, and the proposed new pathways were easily endorsed because

they were modelled on those he had experienced before. And thirdly, the

pride in the success of the new TC once it was underway at Site E reinforced

the staff desire to conform to its methods of working.

At Site G, the success in innovating clinical practice may have occurred in

part because of the appointment of a group of middle and senior managers

with a strong business ethos, and, later, the arrival of a new chief executive

who had a more open, participative management style. These new managers

brought with them a focus on modernisation and allowed an efflorescence of

innovative ideas that had remained largely suppressed up until then, and

many of which could now be centred upon the TC.

In contrast to Site G, at Site H there was no senior clinician willing to be

identified with the proposed changes, partly because of the local politics of

the split site. But there were several consultants who opposed the change and

made their views known. Progress was therefore slow, and required careful



tactics of individual persuasion, often with limited success because of a

managerial infrastructure that was unsuited to dealing with the rivalries and

suspicions underlying much of the resistance to change.

The senior managers at Site A, when faced with senior doctors who did not

engage with the new ways of working, were unable to make significant

progress in implementing key aspects of the new pathways, such as pre-

assessment and follow-up. This was largely because Site A did not employ full

time consultant surgeons, but used surgeons from the neighbouring trusts

whose patients the TC intended to treat. This meant that there were relatively

limited chances of working closely with them to inculcate a new attitude to

the process of care. Nor did it prove possible – although it was strongly

advocated in at least one internal report – to enforce the clinical pathways by

making them part of the consultant contract.

Site C appeared to fall somewhere between the extremes of Sites H and G.

There existed reasonably good relations between managers and consultant

surgeons, but the reception given to the TC was strongly coloured by the

clinicians’ expectation (based on the local history) of the likely benefits and

losses to their own practice. Some groups within the hospital felt that they

would probably lose out ‘yet again’ in their attempts to improve their

services, and to some extent managers at this TC backed away from this

‘huge big can of worms’ that remained from the recent hospital rebuild. At the

same time, some specialties saw an opportunity to increase their bed

numbers and operating lists and were therefore positive from the outset.

Managers were able to bring these senior clinicians on board to play an

important role in developing a successful TC.

In short, the degree of success in engaging senior support for innovative

practice in TCs depended on various local political and managerial

contingencies, linked both to the local milieu and to the local motivating –

and demotivating – features of the TC and its host trust. But when it came to

overall success or failure of the TC, the level of clinical support paled in

comparison to the broader strategic challenges of patient flow, capacity and

financial flows (Section 6).

7.2 Changing the patients’ experience of care?

The effects of the TC programme on quality of care were mixed and moreover

often subjectively interpreted because there were few, if any, formal

evaluations of the changes. We describe the impact of TCs on care under the

following headings:

• changes in the physical surroundings

• changes in the process and in particular the introduction of new ‘patient

pathways’

• new roles for staff

• changes in the ethos of care.

7.2.1 Physical surroundings

One immediate, and most visible, difference was the purpose built and

patient-friendly architectural designs that several of our TCs introduced. At



Sites D and G, for example, patients found themselves being treated in very

modern looking new buildings (which had both been opened by royalty no

less!). Some of our sample sites, despite being part of the NHS, had all the

external trappings of the private sector, and this made them attractive and

popular with the patients who went there. This was especially true of Site A,

which had originally been built as a private hospital.

I think because of the environment… you often hear people walking through the

door and they go, ooh, it’s just like a private hospital…. People do say it’s

extremely friendly, they’ve really been impressed with the care – we ask

everyone to complete a patient satisfaction questionnaire when they leave and

it’s always glowing... And the other thing is it’s really clean and that makes a

big difference. I have never worked in a cleaner hospital and it’s beautiful and

the domestic staff take great pride, it seems to me. And the place is always

spotless and we have no infection and that makes a big difference.


[Patients] want comfort, they want pleasant surroundings, they want clean

lavatories, they want decent food. And that’s what they get here without having

to pay for it.

(Site A: clinical manager 2)

Site E – a refurbishment of part of an existing hospital – quickly became a

showcase for the TC programme, paraded by the Modernisation Agency, SHA

and the host trust as the epitome of the TC concept, and closest to the model

spelt out by the Modernisation Agency (see Section 1, page 12). Modelled

largely on the Ambulatory Care and Diagnostic Centre, it was housed in

similarly splendid and functional new premises. Leather sofas and low tables

furnished the burnt orange waiting areas, pale limestone tiles clad the toilet

walls and floors and light streamed through a glass ceiling, creating a calm

and airy atmosphere.

Every time I go round there there’s a feel of plenty of space and not many

people and yet they are pushing through much more activity these days… It’s

more like walking into a modern library or modern building than a hospital

which is great. All the clinical type areas are hidden behind that façade and it’s

great. The waiting areas for outpatients are very nice, very comfortable and

very modern with the seating. It’s not typical NHS and I think that’s a good

thing. We need to break the mould really of what the NHS currently looks like –

fuddy-duddy.

(Site E: PCT senior manager)

Site C placed a good deal of emphasis on the ‘modern’, clean, state-of-the-art

look and feel of the TC, seeking to match the existing hospital, which had

recently been built under a PFI arrangement. One difficulty arising from

adopting the same look and feel was that many inside and outside the trust

saw this as confirmation that the TC was merely an extension of the hospital,

offering nothing more than extra capacity.

At Site B, where the TC was never described as such and was housed in

accommodation within the main hospital, it was doubtful whether patients

were aware of being in a different unit, as it was simply a refurbished

inpatient ward. There was nothing here to distinguish the ward from the rest

of the hospital; it retained a rather old-fashioned, slightly worn or ‘lived in’

look. This was in keeping with its function since the ward was used not only

for patients who came in for a wide range of routine surgery but also as a

flexible space for patients who no longer needed to be on the main wards



(known colloquially as the ‘end of stays’). Indeed for many patients, the only

effect of being on the TC that they might notice would be that they were

moved to and from other surgical wards as their condition changed. But the

plans for the second phase of the TC – a new build – were driven by a

different vision that, unlike the present facility which improved throughput

and clinical pathways, would:

[deal] with the quality issue around ‘I’m a patient who’s getting an excellent

pathway in a not so excellent facility’. And it moves to ‘I’m a patient who’s

getting an excellent pathway in an excellent facility’ and that’s my goal, really,

in terms of that redesign. So, it’s not just the efficiency gain with modernisation,

it’s the efficiency gain with modernisation plus ‘God, isn’t this a nice place’ as

well. That’s what patients are interested in.


7.2.2 Innovations in patient pathways

The task of modernising the processes of care was pursued at all of the TC

sites and usually resulted in changes to the protocols that included: some or

all of the booking system, the pre-operative assessment, admissions

procedures, a remodelling of the configuration of clinical investigations and

procedures the patient undergoes, and improved discharge planning and

follow-up. See Appendix 6 for an example of a patient pathway.

Site E was regarded widely as a model of such care, and in fact based most of

the redesign of patient pathways on those that had been produced by the

pioneering Ambulatory Care and Diagnostic Centre in London. The director of

the TC consistently emphasised the use of the TC to redesign working

practices not only to provide better care for patients, but also, thereby, to

meet waiting time initiatives, attract and keep staff and also attract patients

from beyond the local health economy to raise its profile (and income), and

also to spread the word about its innovative design and ways of working.

These innovations included the design of administrative pathways for patients

so as to enable a smoother flow from referral through booking and scheduling

to treatment. This was one of the first pathways to be designed and required

the creation of generic clerical workers to support its implementation within

the TC. The pathway was later used in the contract which the TC negotiated

with the independent sector in order to support their clinical pathways. This

example of partnership working between the TC and the independent sector

also produced a model of care that was later taken up by, among others, a

trust in Scotland.

Such changes appeared at all the sites to a greater or lesser extent.

Admissions were booked in advance, sometimes using new electronic booking

systems, taking note not only of the patient’s condition but also their

availability and convenience. Pre-operative assessment was increasingly

carried out by trained nurses according to clear protocols, and including in

some cases a home assessment questionnaire which the patient completed

and returned by post before attending for pre-operative assessment. The

patients’ journey from pre-assessment through their treatment to discharge

and follow-up typically followed newly developed protocols. These protocols

were generally designed to streamline care; they would try to minimise, for

example, unnecessary delays between different stages of the investigation

and treatment, and to reduce the number of different clinicians and others



that the patient came into contact with. For example, at Site D patient

information gained at pre-assessment and from patient questionnaires was

integral to discharge planning:

So, when I see the patients I will have an opportunity to say, oh, yes, I see

you’ve got 16 steps to your front door. I’ve picked out the red flags and try to

home in on those and come up with, at the end of my session with the patient, a

discharge plan, i.e. whether they feel they’re going to go home with nothing,

want referral to an intermediate care team or maybe just social services or

whether it’s somebody who lives on their own, very elderly, fairly disabled, and

you think, yes, they’re going to need rehab somewhere else, they’re not going to

be a five-day person and at that point refer them to whatever their local facility

is for rehab.

(Site D: manager).

At Site G many of the processes from pre-admission through to post-

operative care were thoroughly overhauled and modernised:

There is a definite sense that things are changing and moving… [B] who was

the waiting list manager, she said the changes had been quite staggering.


Such changes at Site G, many of which were in the vanguard of those

proposed by the Modernisation Agency, were not however confined to the TC

but applied to a whole elective care unit (including a new surgical assessment

unit) of which the TC was now a part. They included:

• telephone preoperative assessment by nurses

• changes in skill mix (including new assistant practitioner and anaesthetic

practitioner roles)

• new operating theatre procedures including a linen-free environment

• clinical pathways reducing length of stay (for example knee replacements

in four to five days, hip prosthesis in three days); these were imported

largely from the Ambulatory Care and Diagnostic Centre when a new

senior nurse arrived who had worked there and began working with

clinicians to adapt them for local use

• music in the recovery room

• discharge lounge

At most of the sites it was nurses rather than – as is traditional – doctors who

normally decided, on the basis of protocols that had been agreed for that

particular condition, when to discharge the patients. Follow up would depend

on the clinical need expected for the condition (and not as so often in the

past, on blind routine) and would perhaps be carried out by community staff

working to agreed arrangements. Follow up might also include such

innovations as, for example, a routine phone call from the ward to the

patient’s home.

That’s an opportunity to find out what your patients thought about the service,

their experiences of the service and have they had any problems. You can then

prevent calls going back to GPs from patients that are maybe concerned about

something that wasn’t particularly explained. You can reinforce post-op advice.

(Site E: senior clinical manager, host trust)

Finally, changes also included making more efficient use of existing facilities

such as extending the standard working day in theatres (including weekends



for elective work) to increase the throughput; or moving patients between

beds, trolleys and waiting or recovery areas in order to free up the space for

other patients in the wider hospital system. Many of these changes involved

the agreement of clinicians to carry out surgery in different ways, such as

doing hernias as day cases or using local anaesthetic.

Very few of our patients – it’s well less than 10 per cent – have general

anaesthetic, so they’re nearly all done under spinal or epidural anaesthesia.

And that means they have good pain control afterwards, it’s easy to keep their

medical condition stable, it also means that we’re able to treat patients that

reflect the whole range of patients requiring this type of surgery.

(Site D: senior medical manager)

As staff became used to the new methods, the list of procedures amenable to

such an approach tended to grow. This was so at Site B, for example, where

more and more surgeons were persuaded of the benefits of working according

to the new principles, such that the capacity of the ward had to be expanded

by the addition of a pre-operative assessment unit to make the whole process

of surgical admissions more efficient. They then began to move some of the

more complex day-surgery to that unit, all of which was designed to make

this short-stay ward even more efficient as a way of dealing with the majority

of routine surgery.

At all the case study sites most of the changes that were described to us were

not particularly new in that the ideas and methods were usually borrowed and

adapted from elsewhere or occasionally from the Modernisation Agency

guidance and learning events (which typically showcased what other TCs

were doing). This suggests a form of innovation that was more ‘exploitative’

of others’ ideas than ‘explorative’. As the following managers at Site A told us

after describing many of the innovations:

That’s the sort of stuff that’s going on elsewhere in the country, so it’s not

groundbreaking.


I guess there is [innovation], as far as we book patients the way we’re meant to

and we admit them on the day of the operation and we use care pathways, but

to me that isn’t radical... that’s the way things should be anyway. If you’re

looking at taking things a bit further and have nurse practitioners doing pre-

assessments or having innovative ways of doing things, we’re certainly not

doing that.


Indeed even at any given site, the new procedures may not have originated in

the TC but elsewhere in the host trust. At Site C, for example, teams led

mainly by nurses who were keen innovators (‘idealists’) were developing new

patient pathways in the TC and rolling them out the rest of the hospital but

this work had already been well underway before the TC was even

considered. There had been nurse-led pre-assessment clinics for nearly four

years within Site C’s host trust. Perhaps, then, we should see TCs not as

necessarily ‘creating’ or originating innovation, but rather as prototyping and

field testing it, which may of course be an equally valuable thing to be doing.

As one service improvement manager explained, the use of these

‘innovations’ in the TC could be used as a catalyst for change in the wider

trust/hospital, or simply part and parcel of the wider change process:



The trust has learnt from the fact that they built this new hospital, we moved in,

and we didn’t change our processes. We transferred old processes into a new

build. It was a huge job moving here. It’s easy to reflect and want to do it

differently but I think the learning has been that for the treatment centre we do

want to try and do things differently… in some sense people could argue that

[the TC] is an extension of the hospital and because it is that far away from the

main hospital we can’t make it completely different. So, it creates a double set

of challenges. It’s not about just making what happens in the treatment centre

right and best practice and leaving the activity in the general hospital area

behind. We’ve got to make both areas and move forward together. Our chief

exec has been very clear that we don’t want a centre of excellence in the

treatment centre and the focus on the main site in terms of improvement to

diminish. Whatever happens in the treatment centre has got to be transferred

over to the main trust, but already in the main trust we’ve got things that are

happening that will be transferable in[to the TC].

(Site C: clinical manager).

The point was that in each site, each new development was, for that TC, an

innovation that invariably had to face local resistance from one source or

another. This was felt most acutely by a specialist manager who was brought

from overseas to manage one of the TCs and who struggled with a moderate

degree of success to increase day surgery to levels that would be quite

normal at many sites in the UK and further afield. Yet locally this was

regarded as almost revolutionary, and the manager found it hard to achieve

for the most mundane of reasons:

He gets very frustrated at the pace of change within the NHS, and he’s also

been heavily involved in theatres, because that’s his background as well,

…getting things started on time, and encouraging nurses to take on slightly

more extended roles, so they can scrub-in, or assist, or whatever, and then …

looking at the restructuring of pre-assessment, and outpatients.


Usually the tensions between the ‘idealists’, the ‘sceptics’ and ‘pragmatists’

ensured that many sites not only experienced, as we have seen, mixed

success but also ambivalence in the very introduction of the changes

expected by the modernisation agenda. At Site C, for example, as the TC was

increasingly constrained by the wider financial and political problems of the

host trust, one of the ‘idealists’ was still required to work on a programme of

redesigning pathways and staffing. The work was having very little impact,

especially given the TC’s now very small size:

I was part of the treatment centre project and look at role redesign. So, I was

contracted for two days a week for six months, which finishes at the end of this

month, to work with the treatment centre team. I have to say it’s been quite a

frustrating experience which culminated in me going to see [L] and saying I’m

struggling, really, because the message I was getting was we don’t need

workforce redesign, we’re just going to have more of the same and everything

will be absolutely fine.


Site D was committed to the introduction of new pathways modelled on its US

‘mentor’ organisation, but ran into serious tensions and difficulties with a

number of influential consultants over the introduction of the advanced nurse

practitioner role, on which many elements of the pathways relied, such as

pre-admission and ward cover. Site F’s introduction of innovative patient

pathways was, as we have seen, dismissed by many of the consultants as



unsafe or unworkable (despite the success of similar pathways elsewhere in

the country) on the grounds that very few patients fitted the ‘bureaucratic

template’. That view in Site F had more or less prevented change, but at

other sites similar views were not sufficient to block the innovations. A senior

surgeon/manager at Site B, for example, had started out as a TC sceptic but

upon retirement had been persuaded to do a number of day surgery lists.

Progressively he became a ‘pragmatist’ convert and a stalwart of the new

pathways, helping to develop a pathway for hernia repairs. But nevertheless

he was keen to point to its limited scope:

It’s more or less a transcription of what happens anyway really. It’s a little bit

streamlined, speeded up, although it’s most probably done, at least partially,

with the smoothness of the operation in mind rather than – I don’t mean the

surgical operation, I mean the whole thing – rather than the patient… But if the

patient doesn’t fit the first box, nobody’s interested… The trend is to identify

within the whole morass of the health service bits that can be cleaned,

identified, counted, costed and get on with that. Day surgery, treatment centres

coming in, the cancer work being centralised, just because it’s a good idea

clinically to have the expertise but because it’s a way of dealing with it that is

more uniform. The worry is what’s left and how that’s going to be managed.

(Site B: senior clinical manager)

At Site H a major stumbling block over pathways centred on consultants’

reluctance to give up control of their lists as required by a redesigned booking

system, although the manager responsible for encouraging the change

recognised the validity of some of the clinical arguments and altered the

staffing accordingly. There are several features to note in the following

example:

• the persistence of the local politics and rivalries between the host trust’s

two hospital sites’ methods of working

• the struggle for control over the system for choosing and admitting

patients; the potential wrecking power of the consultant body

• the perceived strength of the clinical argument; the deference of the

managers on clinical issues despite their scepticism about some of the

consultants’ motives

• the pragmatically negotiated solution to allow the innovation to move on.

But above all it is worth noting how the sheer mundane familiarity of such

contested, negotiated order, such as can be found in almost any hospital on

any given day, was an integral part of the detailed design of the treatment

centre – in this case a new clinical staff member to schedule operations:

The surgeons are very much more in control and they will seemingly – in some

cases arbitrarily – pick patients off who haven’t been waiting very long and put

them before patients who have been waiting quite a long time. In their minds

there must be some reason for it. I mean it’s not just that they’re urgent, but I

think there are a couple of issues. Control is definitely one of them. They want

to be in control, they don’t want the administration to be in control. They see it

as a clinical issue and I think that’s a valid point… Historically [Hospital 1 at

Site H] has had the waiting list office which booked all patients, whereas

historically here [Hospital 2 at Site H] the secretaries control the lists, and there

has been huge resistance to having a centralised waiting list function. And

there’s lots of good reasons for that, not the least of which is that at the moment

there isn’t anybody clinically qualified working in the waiting list office. So, a

lot of the time there are mistakes made because the staff don’t actually

appreciate what they’re doing when they’re putting a list together. Now, one of



the things that I have insisted on is that in the treatment centre the schedulers

are overseen by somebody who has clinical qualifications. So there’s like a

scheduling manager type of person who will be clinically qualified, preferably

theatre.


A further example from Site H shows the pragmatic way in which decisions

needed to be made about the design (and resource implications) of another

innovation. In this instance some local investigation into the causes of

cancelled operations revealed a key factor for the success of the TC whose

solution – a pre-operative telephone call – then depended crucially on further

complex negotiations for additional funding:

When [R] did his work on cancellations, the majority of cancellations are

actually day cases. We imagined that we were going to find out that bed

pressures were going to be the cause, and it wasn’t that at all… There was an

equal proportion of DNAs [patients who ‘did not attend’] and medical

cancellations, whether they were the patient decided that they didn’t need the

surgery anymore or the doctor decided but decided on the day, because of

course they hadn’t been seen. So the idea of this redesign service is that in the

case of day cases, if they are straightforward then they get a phone call two

weeks before they’re due to come in. If for some reason they’re not coming, then

they won’t ever go on and somebody else can go on. If this doesn’t get approved

as a business case, it really will be a big blow to us, but there’s no funding.

This is the problem. That wasn’t something that was going to be funded by the

PCT for the treatment centre


In the event, the TC did not secure funding for this idea because of the

financial deficit of the trust, which led to a vacancy freeze.

Other sites faced with a similar problem of unsatisfactory selection of patients

for the TC (either by their own systems or by the PCTs or Patient Choice

schemes that referred the patients) arrived at different solutions to the

problem. Site G used this as an opportunity to push the boundaries of

surgical practice, for example by allowing patients with complex co-

morbidities to undergo day surgery:

And we’ve probably pushed the limit… the criteria, a little bit, with the

[surgeons]. Because they have actually done an insulin dependent diabetic

through the unit, which is a no-no in this country… And they actually saw the

patient in pre-assessment. So they rang me up and said, rather send this

patient to [another TC] he can be done as a day case, he’s quite happy to come

in here. I said, yeah, fine, bring him in next Monday. We did it and he was fine.

Blood pressure dropped a bit but his diabetes was not a problem. We’ve

managed a couple of others that… a brain tumour, which they [normally]

wouldn’t touch. There was a stroke patient… They’ve actually seen the patient

over in their pre-assessment clinic and they couldn’t see any reason why, as

long as you manage them correctly, with the anaesthetic, that you shouldn’t do

them through the day surgery – and we’ve done them… We’re broadening that

criteria for entrance into day surgery, [but] a lot of the criteria at the moment for

day surgery are very strict.


Several sites also faced problems with scheduling and standardisation, often

because the IT systems were not geared up to cope with the transfer of

patient information between different trusts/hospitals (see Section 6.4.1).

Occasionally there were problems when it became apparent during the

operation that a patient required more complicated surgery. For example at



Site G this necessitated a transfer out of the TC into the main elective care

wards:

One of them had to be admitted – not because of her problem but because when

they actually did the operation – it wasn’t what they had planned to do. … I

think when they actually incised and actually saw the extent of the operation

that was required and they felt that it would be better if she didn’t have fixation

in her toe to straighten it. …you’ve got to put them in bed, really, so we had to

keep her in for two days.


Where did new pathways come from?

As well as describing the improvements to practice we were interested in

understanding how knowledge (evidence) and experience informed the

introduction of patient pathways. As the forgoing discussion has indicated,

some of these pathways were borrowed from external sources – other

pioneers of new ways of working. Thus at Site E, a decision was made to use

patient pathways developed for use at the Ambulatory Care and Diagnostic

Centre. It appeared that there was little dissent from the local clinicians in

adopting these new practices, which were ‘trusted’ as having good

provenance and championed by the TC manager (who was in turn respected

and trusted). The fact that the new pathways corresponded with the

clinicians’ own views of good practice also ensured that there was little

resistance to their incorporation in the routines of the TC.

Site C initially went along a different route, attempting to develop its own

patient pathways. Indeed considerable effort was expended by nursing staff

in particular in trying to develop pathways which in essence took apart

current practice for each procedure and attempted to reassemble it in ways

that improved the patient experience and streamlined care delivery. About six

months before the opening date for the TC a decision to use generic pathways

was made and the team working on integrated care pathways (ICPs) changed

direction: the extended field note below captures some of the debate around

these new pathways at this time:

The chair of the inpatient group meeting asked about ICPs, ‘what were the

timescales?’ Gwen [a senior administrator] circulated a document showing the

various ICPs under development and said that they had ‘had a bit of a

breakthrough last week in developing a generic day surgery ICP’ they were now

hoping to use the generic day surgery ICP as template and slot in ‘specifics’ for

other procedures. Previously the group working on the ICPs had tried cut and

paste and taking bits from other ICPs but then they ‘sat down and did the

generic one from scratch’. This pathway lends itself to arthroscopy and hand

surgery so will be sending adapted version out to ask for comments from the

clinicians involved in these operations. The group will then tackle the task of

writing a generic ‘inpatient’ ICP. While all this discussion was taking place I felt

there was a sense that much of the earlier work on ICPs was made redundant

by this move to generic ICPs, but that no-one around the table really wanted to

articulate this. However, one of the nurse managers did point out ENT [ear,

nose and throat] had done considerable work on a tonsillectomy and nasal

surgery ICP and that the meeting had to be ‘careful’ dealing with this, not to

make them feel that all this work had been wasted. After some further

discussion about the generic ICPs Joe asked, ‘as a manager I want to see how

this place is working differently. What does it do differently as a result of all

this?’. Gwen responded that they were ‘looking at what best practice is and

trying to incorporate this into ICPs’ – so that the result would be ‘not quite



standardised care but that someone coming in now and someone coming in, in

three months’ time would get the same level of care

(Site C: researchers’ fieldnote).

At Site B various forms of evidence were used in the design of the TC, both at

the broad strategic level and to assist in the redesign of specific clinical

pathways. Such evidence was largely based either on their own experience or

that of respected colleagues elsewhere (and a reliance on such colleagues

being knowledgeable about best practice either through contacts or through

the journals) and on other sources such as journals, websites and

professional associations as these collected quotes illustrate:

We did look at evidence. People have looked at the Middlesex [Ambulatory Care

and Diagnostic Centre] scheme. We’ve also looked at our own [day surgery]

centre and we’ve got evidence before our very eyes, which is really quite

helpful. We’ve discussed with the people who are doing [mentions four nearby

hospitals that are designing TCs or day care units].


I must admit I don’t trawl through the literature looking for those things.

Perhaps I should but I don’t… We do our own audits and when we’ve done an

audit we look at research but I don’t personally trawl the literature for that sort

of thing. [Interviewer: But you work on teams that do these redesigns: does that

team ever delegate somebody to go off and find out what such and such

essentially does?] Yes, I’m sure they do because there is a regional committee

that will, a regional radiologists committee that we all meet and there’s a similar

superintendents group, I believe, that meets and the path of national

benchmarking exercise we’re aware of what goes on.

Interviewer: So there’ll be a lot of information sharing, pick up what’s going on

in the grapevine and all of that?

Uhuh. What we have is informal structures because the registrars rotate round

and they come here and say, oh, by the way, do you know that they do it like

that down the road and that sort of informal information gathers.

(Site B: hospital consultant/senior manager)

Actually to be honest, a lot of the ideas for the hernia pathway came from

[nearby hospital]. We used a variation of that… but that didn’t come out of me

sitting round with colleagues from other hospitals.

Interviewer: How did you do that?

I can’t remember. It just came through an informal sort of nursing network,

someone that knew someone that was working on it. It’s something that I have

asked the strategic health authority whether they could facilitate that getting

them together, because people who do my sort of job are quite comfortable with

that. Other areas can be a little bit more competitive, but there is an element of

competition between the two teaching hospitals in one city.

(Site B: nursing manager)

What we’re trying to do now is get all the evidence-based practice from other

areas to support that.

Interviewer: What kind of evidence?

Well, going onto websites to look at who else might be doing a pathway that’s

like this, to have a look at outcomes and things like that so that we can say Mr

So And So and such and such a hospital is doing it this way, they’ve seen such

and such a percentage increase in throughput, it’s just finding out that

information.

(Site B: manager)



Contact with the British Association of Day Surgery has been vastly important

because they kind of explain the basket [term coined by the Audit Commission

in the 1980s to describe the group of operations feasible for day surgery]; they

underpin the work that’s gone on. They present the papers. They present the

kind of work that’s gone on in different trusts around the movement of

inpatients to day cases and those procedures have not just been picked

because they’re there, they’ve been picked for a reason. They’ve been piloted

and tested and satisfaction has been looked at and outcomes of patients and

clinical and satisfaction have been looked at and it’s good…It really is good. It

actually gives a very balanced view because it will equally listen to nurse’s

views as well as medics’ views as well and I think that body has become a very

important body in the development of day surgery.

(Site B: hospital consultant/senior manager 2)

She [a nurse manager] is responsible for putting together some of the [TC]

protocols and I asked her how she went about it. For example she has done the

one on angiography. She said she pulls together the evidence by talking to the

consultants. Most of them have got different views about what patients can be

discharged when, and what the criteria are. She also looked at the journals for

evidence – the journals of day surgery, and one on anaesthesia. But when I

pressed her, what she was looking for was published discharge protocols from

other centres that she could draw upon. That seems to be what she was calling

evidence. It was notable that she made no mention of critical appraisal, trials,

systematic reviews, or any such matters promulgated by the evidence-based

practice movement.

(Site B: researcher’s fieldnote)

7.2.3 Innovations in staffing

Many of the new pathways entailed making changes in clinical roles, which

itself entailed breaking down some of the traditional distinctions between

existing professional groups. At Site A, for instance, there was some blurring

of professional boundaries, with nurses trained to do post-operative

physiotherapy and therapists trained to review GP referral letters in order to

triage and investigate patients, and to decide if they were appropriate for the

consultant to see. At Site B, the trust hoped to introduce a new grade of

health care assistant who would be a relatively junior nurse, and who shared

many of the roles of an operating department assistant, for which that

assistant could also train. They held other, more ambitious, ideas such as the

introduction of non-medically trained anaesthetic assistants in abeyance until

there was more evidence of success elsewhere in the NHS and the local staff

doctors might be more receptive to the idea. Site E, like others elsewhere,

developed pre-operative specialist practitioners with responsibility for pre-

assessment, and also advanced theatre practices by using two theatre

practitioners (one a nurse and one an operating department assistant) to

undertake minor procedures for example taking prostate biopsies. They also

introduced more flexible use of skills such as using nurses to rotate through

theatres, recovery and the short stay areas:

In order to cope with the peaks and troughs through the working day, as well as

over periods of time you need to capitalise on the transferable skills of nurses

in theatres and recovery... The skill is to look after an unconscious patient

regardless of whether that’s in theatre or in recovery

(Site E: senior manager).

Site D was initially envisaged as a nurse-led facility, and to this end the TC

originally intended to be innovative in the ways that the nursing workforce



was used. This included the appointment and training of some 20 advanced

nurse practitioners with the idea that these individuals would not only push

the frontiers of nursing practice forward, but also that they would have an

educative role in developing other key staff such as therapists and health care

assistants. As one of the managers explained, this new role would provide a

new opportunity for nurses:

And the clinical nurse specialist [at another hospital] was so frustrated because

she wanted to do so much, but her patients only just couldn’t do it, because she

didn’t have the resource. But here, at the brand new centre, it’s just a real

opportunity to be able to do so much more ... We’ve been fighting for

professional status for so long and to be able to take over what the doctors are

doing and to be at the forefront, delivering what nurses haven’t done before –

we’ve got fantastic nurses. And if you go speak to any new advanced

practitioners out here, they’ve also got the bug and they just think it’s great.

(Site D: clinical manager)

Sometimes – due to a variety of factors including scepticism and resistance or

an insufficient drive for change from interested professional groups – the

crucial block to the innovations was the failure to achieve those necessary

alternations in staffing patterns, including changes in the balance of different

grades and the introduction of new roles that crossed traditional boundaries:

The place has been staffed in a very traditional way. I would describe the

nursing skill mix as very top heavy – lots of E grades and a lot of F grades as

well as G grades, so it’s been quite traditionally set up. In theatres they want

lots of E grades, there are very few theatre surgical assistants and ODAs

[operating department assistants]. And why it’s happened that way I think it’s

just happened that way, I don't think anybody’s given it an awful lot of thought

to be honest.


Resistance from defensive professional groups was not the only bar to the

introduction of the new clinical roles. There was also the problem of

resourcing the new model, either in terms of finance or the recruitment of

appropriate personnel. At Site D, the original plans had been formed some

years earlier, still with traditional staffing in mind, but – at the time the

opportunists saw the chance to implement those plans as part of the TC

programme – the innovative idea of nurse-led care was enthusiastically

embraced as a new focus of those plans. Unfortunately, the concomitant extra

funding was not. The rationale was to have been that it would use fewer

junior doctors, resulting in savings from which the new nursing grades could

be resourced. However these rather loose calculations were superseded by

the need for those funds to be used as a means of motivating senior doctors

to use the TC. In other words the funds saved by employing fewer junior

doctors were spent on paying senior doctors, not on developing new grades of

senior nurses. Added to this reduction of resources was a problem in the

funding of the intensive care unit that was linked to the TC; a problem that

was chronically exacerbated by its being unexpectedly underused. Thus the

innovative staffing ideas, as well as some of the intended innovative

equipment and associated upgrades, were severely compromised by a lack of

money. Given the emotional investment in the new advanced practitioner role

and the importance of the nurse-led identity to this site, exemplified in the

earlier quote from the clinical manager (above), this lack of investment came

as a heavy blow for the nurses at this TC.



Recruiting and training personnel for the new roles was also often a problem,

as the following manager succinctly illustrated:

One of the main things I’ve looked at is how the health care assistants or the

nursing assistant role can expand because we’re under demand to provide

theatre systems for the theatre team. They’re demanding our experienced staff

to actually fit that. If we do that then we’re going to be depleting our scrub staff.

So, we need to address it from the bottom up then hopefully we can help those

experienced staff to take on an extra role and if we look at the theatres at [host

trust] we’ve got 18 new operating theatres. If you only wanted one member in

each theatre trained up then that means we’re employing 18 additional staff

and [yet currently] we’re having [unfilled] vacancies of between 25 and 30.

Now, that’s not realistic. So, what we’re looking at is other ways around it

really. We don’t have a problem recruiting nursing assistants or HCAs [health

care assistants] so therefore we can train if we want to in part and it would be

like a rolling programme. We could recruit into these posts and as they become

more experienced and we can put them on the skills escalator to achieve those

additional competencies.

(Site B: clinical manager)

Thus, even when they had everyone’s agreement, the strategic intentions of

new staff grades, without which the innovations within the TCs could not be

maintained or developed, required very detailed operational manoeuvrings.

Moreover, such internal shifts occurred in the broader context of schemes to

recruit people to nursing – such as the re-establishment of a ‘massive’ drive

to recruit ‘cadets’ in the region concerned, an associated revamping of the

qualifications ladder from school leavers through to qualified nurses, the

development of new curricula and assessments, new gradings and salary

scales linked attractively to other career ladders such as operating theatre

orderlies, and so on – and all this in the broader context of economic and

demographic trends that were impeding recruitment to the health care

professions at every level.

The shortage of suitable personnel – in this case surgeons – to undertake the

required work for TCs led two of our sample sites having overseas surgical

teams flown in to do regular operating lists, and these did succeed in

attracting highly qualified surgeons from abroad. At one of the sites, this

seemed to produce constructive mutual learning with overseas surgeons

interested in sharing knowledge and techniques, but also learning from their

NHS counterparts. While viewed positively within the trust, the arrangement

was not without its critics, however, for example from at least one surgeon

from further afield, who objected on principle to having patients sent from his

waiting list to a distant unit to be operated on by ‘foreign’ surgeons. The

other site using overseas surgical teams, which had already used such teams

before the TC opened, found that the experience helped persuade some

sceptics to see the relative advantages of ‘factory’ type surgery. The

successful experience of having foreign doctors not only provided evidence

that the trust could take on these types of projects, but also lessons for the

design of the TC:

I think we’ve learnt as well because you may have heard that last year, last

June to September we ran on this site upstairs here ..[an].. overseas clinical

team, and that was very much on the basis of – if you like – it was a sort of

treatment centre for [specialty] surgery and we could see the advantages of

doing that, but also the significant disadvantages. I mean there are advantages

of throughput and efficiency, but the issues of continuity of care pre the surgery

and then post the surgery were really major, and it opens up some serious



questions, for instance around the [Patient] Choice initiative and moving

patients between services. The fear is that the loser in that situation is the

patient who gets a discontinuity of care and certainly what my feeling is we

should look and try to avoid that discontinuity of care through our treatment

centre. It should be integral with the rest of the care that patient’s receiving.


One of the workforce issues picked up early on by the critics of TCs was the

potentially negative impact of these centres on surgical training (Section

4.1.3). The pressure on TCs to increase activity and throughput was seen by

some commentators as a bar to undertaking training in this environment (the

argument being that the presence of trainees would slow this activity).

Professional bodies such as the British Medical Association argued that the

removal of routine work from the mainstream of hospital activity would

diminish the training offered to junior surgeons, both by removing the less

complicated procedures (on which the very junior trainees might begin to

learn) and decreasing the overall number of training opportunities. As we

have intimated (see Section 4) not all our case study sites took the view that

training was precluded within the TC: indeed Site C welcomed the

development of the TC as a chance to promote training. Given the relatively

high profile of the debate about training in the media and professional

reporting around TCs it was striking that this issue was not discussed more

either in interviews or when we were observing the TCs. The one foray into

this territory we gathered was this view, from a regional workforce manager

linked to Site A. This respondent was concerned about the potential impact of

the TCs on medical training:

It’s based on the premise that you’re taking elective work out of surrounding

hospitals. Therefore it affects, in theory, the experience that junior doctors were

getting in training within those hospitals. And, indeed, the most noticeable case

was [hospital X], who planned to move their entire orthopaedic elective over to

[Site A]. The questions they asked were, if we do this, what happens to our

training great doctors, i.e. will they lose approval [as a training site] because of

the change in the clinical experience?


7.2.4 Different (‘can do’) mentality

Finally, in terms of the innovative care being delivered in the TCs, it is

important to stress that there were often units where the front-line staff did

cultivate a different, and very distinctive, ethos from the rest of the hospital .

At Site B, for example, staff were clearly focused on getting patients through

the system efficiently, and fiercely proud of their reputation for innovation

and flexibility. Although this TC was integrated with the rest of the hospital,

its innovative ways of working coexisted comfortably with the more traditional

attitudes elsewhere in a trust which, according to TC staff, lacked its own ‘can

do’ mentality:

The TC ward manager/sister… told me how they had been trying to transfer a

patient and the main ward wasn’t able to take them. ‘What’s the hold up?’, we

said. ‘We haven’t got a bed made up’, they said. ‘Right we’ll come and make

the bed for you’ which we rushed up and did straight away and that way

everybody’s happy

(Site B: researcher’s field note)



In this and many other ways, TC staff tried to ensure that their philosophy

was understood and appreciated by the rest of the hospital. This kind of ethos

often engendered a feeling of almost euphoric belonging among front line TC

staff, which ultimately linked to much greater – and real – ‘patient-focused

care’:

It’s exciting! We’re not standing still. There’s lots going for it and there’s a great

future. And I see it expanding greatly. I think that is very good for us, the

people, and everybody.

(Site E: theatre manager)

That’s why I say we’re special because we give [patients] information what they

want, where other clinics don’t. There’s ‘next, sit down, wait for your number’.

But we don’t do this. We have a personal relationship with the patient… We do

a little bit extra than we need to do… I chat to my patients, I don’t just make it a

formal interview. It keeps them calm and relaxed and they enjoy the experience,

and that’s what we want. We want a DTC [diagnosis and treatment centre] to be

an enjoyable experience… We sort out the social problems here. I had a case

yesterday where I had to sort out this 80-year-old in a wheelchair who lives on

the fourth floor in a flat without a lift. He’s come for a knee replacement.

Surgeon comes to me and says can you sort this out for me? I had to sort out

the housing scheme… you see that’s part of my extended role.

(Site F clinical manager)

For some staff the development of the TC was also central to their own

personal or career development, nowhere more so than at Site G where the

project to get the TC off the ground represented a unique opportunity for

some relatively junior staff to develop project management skills. The small

team who managed the early development of the TC exemplified the ‘can do’

mentality – summed up neatly by one middle manager (who incidentally had

worked her way up the career ladder having joined the trust several years

previously as a clerk):

You can’t expect to sit back and let things come to you. Sometimes you feel they

should, but more often than not, you have to go out and get, you have to go out

and find it. No one else will help you deliver – you have to do it yourself.

(Site G: middle manger)

We are not in a position to determine how far individuals like this self-

selected into positions linked with the TC, but it is clear that the TCs did

provide important developmental opportunities. It is worth noting that we

rarely found examples of disillusionment or defeatism. The one example

which counters this view of a ‘can do’ mentality comes from a nurse manger

at Site C, which had undergone recent relocation to a new hospital build: for

this individual the TC represented yet another change at a difficult time, and

at too great a speed:

There’s no additional time. There wasn’t any additional time last time round

either and there definitely isn’t this time and that does cause complex… When

planning for the treatment centre everything seems to have had quite short final

times, like 24, 48 hours for some things. I got back from two week’s holiday to

be told, ‘I’m coming up in an hour to sign off some drawings!’. To me that has

felt really quite rushed and potentially quite risky compared to the timeframes

we had last time.

(Site C: nurse manager)



7.3 Summary: the struggle for a glass half full

In chronicling the formidable challenges that local TC managers faced as they

struggled to overcome traditional mindsets and ways of working, one begins

to put the scale and scope of an innovation such as this into perspective. To

some observers the changes we have described may appear fairly small-scale

and undramatic, almost routine (‘first order’ improvements rather than

‘second order’ transformations) but from the view allowed by the case studies

– and from where the innovators themselves were sitting – we can begin to

appreciate just how ‘revolutionary’ and hard-won the innovations often were.

It is important as outsiders not to underestimate what was achieved – and

seen to be achieved – on the ground.

As this section has shown the TCs were seen as bringing about real change

and improvement in the way patients were treated, for example in better

scheduling and throughput, or in the protocols of care that patients

underwent. However it was also clear that there were different perceptions of

that change process, particularly in relation to the scale and degree of

‘success’ of innovation. For example in one site we heard from one senior

manager that:

There has been no innovation around staffing, recruitment and process. Looking

at other types of posts, you know, we don’t have a nurse consultant, we don’t

have a nurse specialist, we’ve got pre-assessment clinics being run by

consultants. … It’s all very traditional. Theatres are exactly the same – a very

nursing, top heavy skill mix… there has been little thought as to what

operations are we going to do and therefore what skills do we require and does

it have to be a nurse – there hasn’t even been that sort of line of questioning.


Yet, in contrast, two other clinical managers from the same site told us that:

They [patients] love the clinic, they really, really do. The reason why is because

they come in, they get all the attention, they see everyone they need to see, we

do everything on them that we need to do and work with the outcome – a day

for the operation, or for the six month follow up… Some patients call it a one

stop shop because it took the patients 52 steps to get to surgery, whereas it

took us two steps. I think it’s a very grand, very posh clinic… I bring in plants

as well and make it friendly for patients. And I’m busy doing the reception area

as well. I’ve put some plants in there, and I’m going to get paintings and hang

paintings. So it doesn’t look like a clinic, it looks more like a living room. What

we try to do is play classical music as well because it makes people calm.

(Site F: clinical manager)

At least you’ve got a decent, clean, fairly new ward that can work as a day

case unit. That’s something; it’s better than nothing at all.


Although it was not within the remit of the current study to provide a

quantitative assessment of the extent of change ‘achieved’ by the TCs,

remarks like these allowed us to reflect the views of those ‘on the front line’

of making these improvements to practice. Here at Site F it appeared that

there had been little major change in the attitudes of senior clinical

(especially medical) staff, and that attempts to introduce formalised patient

pathways, which had made little impact on lengths of stay for elective

surgery, had often been ignored by the doctors, who continued to rely on

long-established procedures for pre-operative assessment, admission and



discharge. Nevertheless, even here, we could see that the introduction of the

TC resulted in a marked fall in the waiting times for many operations, and

nurse managers also made considerable strides in improving the patient

experience before the unit was forced to close for lack of patients.

At Site H, where the TC was still developing when we finished our fieldwork, a

disappointed service improvement manager told us that the TC had not done

anything ‘really innovative’. Yet our impression in comparing their

achievements with some of the other case studies was that this site was

much more in tune with the modernisation agenda than most; the project

manager had worked a good deal with the Modernisation Agency, had

rescheduled and relocated elective care, introduced patient pathways, hired

visiting teams of overseas doctors who had helped reduce waiting times, and

was now spreading some of the new practices further across the trust.

Latterly the key barrier to further developments in improving practice was the

financial crisis of the host trust which put a halt to further expenditure around

modernisation and/or redesign.

At Site A there was considerable clinical pathway development work, but

(perhaps because of the failure to engage the surgeons most of whom were

employed elsewhere and worked as visiting specialists) managers believed

there to be relatively few innovations in the actual surgical care that was

given. However they also admitted that this was difficult to judge because

there was no benchmarking against which to compare other services or the

parent trust’s own status quo ante.

Here I think that there are certain things that we now take for granted, as

normal practice if you like, whereas when I go to other places, they go ‘ooh,

that’s a good idea!’ and I think, ‘oh that’s really basic to us…’ So I think we are

still innovative. I don’t think, if I’m really honest, we’re not always as innovative

as we like to think we are… But having said that, we’re making a lot of

changes, in terms of day surgery, getting regional blocks, and sending patients

home without any alarms, and so there is a lot changing, but it’s changing, it

hasn’t necessarily changed.


As a final example of the problem of assessing the impact on clinical practice

of TCs with such mixed fortunes, Site D claimed in one communication that:

The innovative treatment and the high standard of care that [patients] receive at

[Site D] will continue and further improve… [Site D] is already a local centre of

excellence. By allowing an independent provider to manage these services, [it]

can become a world-wide centre of excellence. [Site D] will continue to treat at

least the same volume of NHS patients and all local people will still have the

choice to be treated at the centre.

(Site D: press release)

Such claims – which were of course part of a campaign to justify the

involvement of the private sector in the face of some fierce opposition – were

not far-fetched. Yet this TC remained in serious operational difficulties and

had an uncertain future. Despite all the problems (see Section 6) of poor

planning, overcapacity, financial setbacks and the evanescence of the

principle of nurse-led care, there were some remarkable changes in the type

of care that patients received here. These included a pre-operative

assessment done by nurses via a questionnaire, a nurse-led clinical pathway

about which patients were supposed to be fully informed before arriving at



hospital, well-honed individual care pathways with key milestones (based

albeit controversially on US models), case managers in charge of discharge

planning, PCTs providing planned intermediate care, and considerable

redesign of the workforce in order to accomplish these new ways of working.

On balance, then, the view from people working in and around the TCs was

mixed, albeit broadly positive. Some saw (and were proud of) changes they

had made to the delivery of care. Others were frustrated at the incremental

nature of change and had hoped for more radical transformations which they

felt were yet to be realised. Our sense as outsiders is that many of the

changes we have described in this section were indeed incremental. They

represented small, often low level changes to ways of working, adaptations

and continuations of change processes already in train, often borrowed from

elsewhere or developed within the host trusts. But we should not ignore the

fact that what may be first order to an outsider may feel very much a second

order change to the insider. And they nonetheless represented some marked

improvements to practice.



Section 8 Quantitative studies related to treatment centre operation

Alongside the qualitative evaluation of TCs, part of the SDO project proposal

concerned the application of mathematical modelling methods to examine

aspects of TCs in relation to quantitative issues such as patient throughput

and capacity. This quantitative work accounted for a relatively small part of

the project budget (15 per cent). However, in the event, far more was

achieved than was originally envisaged, at no additional cost. Such are the

vagaries of research in mathematics.

A good overview of the core of the quantitative work may be obtained by

quoting from the original proposal:

The intention is to use mathematical modelling based on stochastic analysis

techniques, using methods from probability theory to describe the flows of

patients through their treatment pathways. This has parallels with a branch of

operational research concerned with the analysis of queues. Such stochastic

methods allows the analysis to take account of variations in factors such as

length of stay, variability in the scheduling of admissions and non-

homogeneous case mix within a particular unit. Such methods have already

been exploited successfully in relation to the analysis of booked admissions

(Gallivan et al, 2002; Utley et al, 2002a). These recent studies have highlighted

the central role that the variability of length of stay has on capacity needs. The

more variability there is, the higher the capacity needs (since one cannot base

bed planning simply on average needs). The introduction of [TCs] provides a

potential mechanism to counter this. Although length of stay is variable from

patient to patient, there are some factors that can be used to distinguish

between patients likely to have a longer length of stay and those whose stay

will be shorter. Such factors include the procedure being performed, the

patient’s age, existing co-morbidities and whether the admission is emergency

or elective. Given this background, the research team recognises that whatever

their other merits, [TCs] have a particular attraction from an operational

research perspective in that they present a means of exploiting a particular

feature of the ‘economics of scale’ that has not been feasible within traditional

NHS hospital structures.’

This very much describes the quantitative research that has actually taken

place within the project. By good fortune, early on in the project, a discovery

was made that allowed the application of powerful techniques from the field

of mathematics known as optimisation theory. This meant that, when

considering inpatients, a unified approach could be adopted to deal with the

complex interactions between capacity, length of stay variability, case mix

and booking decisions. This will be the main focus of the present section.

The operation of outpatient services does not have the same scale of

complication related to length of stay variability, although it does of course

play a part. However, there are still difficult planning issues that have to be

resolved. Again it was found that methods from optimisation theory could be

applied.

These streams of research very much address questions related to providing

analytical tools to help to improve the operation and planning of TCs and

these will be the principal topic of the present section.



As outlined in the passage quoted above from the original proposal, the

quantitative researchers have also investigated questions associated with

economies of scale in relation to the use of capacity. Here, there is a trade-off

between increasing capacity in non-TC centres, thus benefiting from

economies of scale, and the potential benefits following from better

management of length of stay variability that might follow from introducing

TCs or increasing their capacity. From an SDO viewpoint, the emphasis of the

research question thus changes from ‘how can one make a TC operate

better?’ to ‘under what circumstances is the introduction of a TC an effective

use of capacity?’. This issue is an order of magnitude more difficult to address

and of course should not be seen in isolation from other more qualitative

issues associated with TCs. Work on this is discussed in Section 9.

We are aware that some of the mathematical modelling that has been carried

out is rather technical in nature and full details of this would probably be

unpalatable to many of the readers of this report. Fortunately, most of the

key findings are contained in peer reviewed papers that have been either

published or accepted for publication (Gallivan, forthcoming; Gallivan, 2005;

Gallivan and Utley, 2005; Utley et al, 2005; Utley and Gallivan, 2004). Here,

we shall avoid mathematical detail as far as possible and restrict our

attention to summarising the main findings in non-mathematical terms.

Where explicit formulae are given, a ‘cartoon’ style is adopted with the

implication that a precise understanding of the technical detail of the formula

is not a necessity on the part of the reader and all that is needed is

reassurance that such formula exist. Also, on occasions we quote passages of

text virtually verbatim from these, our own, publications.

8.1 Background – the key role of variability in determining capacity requirements

Scheduling and queuing are both complex matters that arise in a wide variety

of contexts including manufacturing processes, telecommunications and

transport. ‘Operational research’, the mathematical field that covers such

matters has shown that, if a system is operating close to capacity, small

changes in the way in which a system operates can have major knock on

effects. For example, well-intentioned changes to the strategy used to control

the traffic lights in an urban road network can, if the system is operating

close to capacity, result in gridlock.

Does this have any relevance to NHS operation? Certainly the NHS is a

complex organisation and at times appears to operate close to capacity. An

uncomfortable question arises. If the NHS is indeed delicately balanced close

to the cliff edge of overload, is it conceivable that the introduction of new

mode of operation, such as TCs, might actually degrade performance?

Drawing parallels with traffic control, there are three key factors: reserve

capacity, unpredictable variability and blocking. The interaction between

these has a major impact on the efficient operation of the health service and

various operational research studies have investigated such issues (for

example Millard et al, 2000; Worthington, 1991; Harris, 1986; Shahani,

1981; Harper and Shahani, 2002; McClean and Millard, 1993, 1995; Bowers

and Mould, 2002, 2005; Costa et al, 2003; Mackay and Millard, 1999; Bagust

et al, 1999; Bensley et al, 1995; El-Darzi et al, 1998). Surprisingly, in



practice, NHS managers seems to pay relatively little attention to the

variability of length of stay. Equally, it is uncommon to keep records related

to constituent parts of a hospital episode, such as the time spent in intensive

care or in a high dependency unit.

In an earlier paper (Gallivan et al, 2002) we discussed the central role of

variability in length of stay on capacity requirements, illustrating this using

an example based on intensive care following cardiac surgery. The notions

discussed in that paper are central to the analysis underlying the present

work so it is well worth restating them.

A common (and erroneous) method for estimating bed capacity needs for a

unit is illustrated in Figure 2.

Figure 2 A conveyor belt model often erroneously used to estimate bed capacity

needs

Unfortunately, while such a simple model seems appealing, it is erroneous

and indeed very misleading since it takes no account of variability.

We devised a mathematical model to examine the effects of variability of

length of stay on capacity requirements of a post-operative cardiac intensive

care unit in the context of a booking system for cardiac surgery. The model

was based on the use of probability theory. As is common with mathematical

modelling, many of the complexities of real life hospital operation were

neglected, the purpose being to examine the principles underlying the

process. Within the model, it was assumed that a regular and unvarying

number of operations are booked each day, each performed successfully, and

each resulting in a patient being admitted to intensive care for post-operative

recovery. Patients were assumed to remain in intensive care for a whole

number of days, the duration of their stay having a pre-specified probability

distribution. Patients were assumed to be homogeneous in that the same

length of stay distribution applies to each. Lengths of stay were assumed to

be independent of one another and also independent of the number of beds

occupied. The specific length of stay distribution used was based on real data.

The histogram in Figure 3 is derived from the mathematical model and

indicates the probabilities of different numbers of beds being occupied. These

are calculated from the number of cases assumed to be booked each day and

the distribution of length of stay. The histogram is centred on the number of



beds that would be required if there were no length of stay variability. The

tails of the distribution occur as a consequence of the variability in length of

stay. If by chance, a group of patients are booked whose post-operative care

requires longer than average, then more beds would be occupied. The upper

tail of the distribution indicates the probability of such an occurrence.

This mathematical model starkly illustrates how variability poses a

fundamental problem associated with booking and bed capacity provision.

The average length of stay was 1.65 days. Since five operations per day were

assumed, this corresponds to an average requirement of 8.25 beds. Ignoring

variability in length of stay, an eight-bed or nine-bed intensive care unit

would seem appropriate for this level of bed requirement. However, variation

in length of stay means that operating an intensive care unit with eight beds

would lead to operational overload 41 per cent of the time (for a nine bed

unit, this figure would be 22 per cent – see Figure 4). Increasing the number

of beds to give reserve capacity would be the only option. However, to reduce

the chances of operational overload to 5 per cent or less, then as many as 11

beds might be required. In capacity terms, this would correspond to

maintaining a unit with over 30 per cent reserve capacity. This is clearly

possible, but expensive.

Figure 3 The distribution of bed demand derived from the mathematical model

discussed in Gallivan et al (2002)

Number of beds required

16151413121110987654321

Probability

.25

.20

.15

.10

.05

0.00



Figure 4 Modelling the probability that there is a booked admission but no bed

available dependent on the number of beds available (taken from Gallivan et al,

2002)

To make matters worse, this initial mathematical model was deliberately

simplistic, the philosophy being that a booking system that fails to operate

effectively when applied in simple circumstances stands little chance when

used in the real world. The mathematical model used in the British Medical

Journal article (Gallivan et al, 2002) was designed to illustrate a point of

principle – that variability in length of stay complicates the policy of

admissions booking and gives rise to increased capacity needs. The model

was not intended as a tool to be used for planning purposes (although it

would certainly be more realistic than using conveyor belt estimates) in view

of many factors that had not been taken into account.

Later work (Utley et al, 2003) extended the model to include other key factors

as illustrated in Figure 5. In addition to variability in length of stay, this

allowed consideration of issues such as ‘did not attend’ (DNA) rates,

unpredictable emergency admission rates, and patterns of admission booking

that vary according to the day of the week.

Figure 5 Modelling bed capacity needs taking into account multiple sources of

unpredictable variability (based on Utley et al, 2003)



Somewhat surprisingly, even though several complicating factors had been

introduced, it was found possible to derive explicit, although quite complex,

mathematical formulae for the mean and variance of bed demand and how

these vary during the week.

8.2 Example: the use of modelling in treatment centre planning

It is useful at this point to consider how such modelling could be of use to a

health care manager. The example discussed in Box 1 concerns an actual

planning problem that the authors were asked to help with. Although the

planning problem discussed arose as part of this study, it does not relate to

one of the formal case study sites discussed elsewhere in this report. The

account given is based on that given in Utley et al (2005).

Box 1 The setting

The example concerns one stream of clinical activity in a TC housed within a larger

acute hospital. The TC manager had reached agreement with the wider hospital

management concerning the level of patient throughput that the TC unit should

deliver. This level of activity was largely influenced by the number of general surgery

procedures that would be required to meet Government targets concerning the

maximum waiting time that patients should face. At the time of the planning exercise

described in this section, the TC manager had agreed on an operating schedule with

the available general surgeons and was in the final stages of arranging anaesthetic

cover for this schedule and planning post-operative care facilities.

The questions the manager had to answer were:

1 What level of bed capacity is appropriate to cater for expected demand for post-

operative care?

2 To what extent are bed capacity requirements affected by a predetermined cyclic

pattern of admissions for surgery?

3 To what extent are bed capacity requirements affected by unpredictable variability

in patient post-operative length of stay?

In this simplistic statement of the problem, the focus is on the provision of

beds. It should be noted that along with the physical resource of beds, this

planning problem also relates to the attendant level of nursing cover that is

required for post-operative recovery and many other resource issues such as

equipment requirements and demand on hospital catering.

8.2.1 Planned theatre activity

The planned theatre activity was determined by the TC manager in response

to two key constraints:

• the number of patients that needed to receive an operation within the

planning period required in order for the organisation to meet

Government targets relating to maximum waiting times

• the availability of general surgeons and anaesthetists.



After negotiation with surgeons and anaesthetists, the TC manager decided

on the weekly schedule for theatre activity relating to general surgery given

in Table 3 below.

Table 3 The repeating weekly cycle of the planned number of general surgery

cases

Day of week Number of patients planned

Monday 6

Tuesday 6

Wednesday 8

Thursday 8

Friday 9

Saturday 0

Sunday 0

8.2.2 Length of stay distribution

The exact distribution of length of stay for patients was not available since

this planning was being done before the new service came into operation, and

thus direct observational data were not available. Also, it was considered

unwise to use length of stay distributions for patients from another hospital

setting, since the new TC service was intended to treat only routine cases

which was expected to have the effect of curtailing the length of stay

distribution. An estimated distribution was constructed by the research team

in conjunction with the TC manager and the hospital's information manager

to reflect the ‘realistic target’ length of stay for surgical patients. Since the TC

planned to select patients deemed less likely to have an extensive post-

operative recovery, the shape of the distribution was chosen to have less of a

‘tail’ than is typical for post-operative care in traditional hospital

environments. The distribution chosen for use in generating planning

estimates is given in Table 8.2.

Table 4 The post-operative length of stay distribution used to generate the

planning estimates of post-operative capacity requirements

Length of stay (days) Proportion of patients

1 36%

2 47%

3 10%

4 5%

5 2%

It was assumed in this case that the length of stay for all patients using the

TC could be approximated using this distribution. It was also assumed for the

purposes of generating the planning estimates that patients could be

discharged on any day of the week, including weekends, and that patients'

length of stay was not affected by which day they received surgery. Although



this might be an unrealistic assumption in some hospital contexts, weekend

discharging is one change in practice that is being encouraged within TCs.

8.2.3 Results

The mathematical model outlined in the earlier parts of this section was used

to calculate the distribution of requirements for post-operative care beds,

based on the data relating to length of stay variability and patient admissions

given above. These calculations were performed using a Visual Basic for

Applications routine written by the authors to implement the model within the

Microsoft Excel spreadsheet environment.

Distributions of post-operative bed requirements

As the number of patients undergoing surgery varies throughout the week,

the distribution of bed requirements is different for each day of the week.

Figure 6 shows the distribution of bed requirements for a Monday and a

Friday respectively.

Figure 6 Distribution of bed requirements on (A) a Monday and (B) a Friday

based on length of stay and admissions data given in this section

To summarise the results, we plotted for each day the mean bed

requirements and the upper 95 percentile of bed requirements. The graph

showing the weekly cycle of bed requirements is shown in Figure 7.

Bed requirements on a Friday

0

5

10

15

20

25

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Number of beds

Percentage of days

Bed requirements on a Monday

0

5

10

15

20

25

30

35

40

45

50

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Number of beds

Percentage of days

A

B Bed requirements on a Friday

0

5

10

15

20

25

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Number of beds

Percentage of days

Bed requirements on a Monday

0

5

10

15

20

25

30

35

40

45

50

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Number of beds

Percentage of days

A

B



Figure 7 Mean post-operative bed requirements and the upper 95% limit of bed

requirements for each day of the week

Evaluating a particular level of post-operative bed provision

The distributions of bed requirements presented in the previous section were

calculated using the assumption that no operations would be cancelled due to

a shortage of post-operative beds. These results can be used to explore the

likely impact on the TC of providing a given number of post-operative care

beds. This is done by using the calculated distributions of bed requirements to

calculate the proportion of days when requirements would exceed a given

capacity. This provides an estimate for the proportion of days on which the TC

would face operational difficulties whereby extra post-operative beds would

have to be provided to avoid the cancellation of scheduled operations. For the

current example, Figure 8 shows the proportion of Fridays on which bed

requirements exceed capacity for different levels of capacity that could be

provided. To highlight the folly of basing capacity plans on average lengths of

stay, the capacity corresponding to average bed requirements is marked.

Daily bed requirements

0

5

10

15

20

25

Mon Tues Wed Thurs Fri Sat Sun

Day

Beds occupied

Average

Upper 95% limit



Figure 8 The percentage of Fridays on which demand exceeds capacity for a

range of possible operational capacities

Note: The dashed line shows the capacity that corresponds to average requirements.

These estimates proved very useful to the health care manager concerned,

who used the results to lobby within the host trust for greater provision of

post-operative beds within the TC.

8.3 Extension of modelling to better reflect the context of treatment centre operation

The problem presented by unpredictable variability is not so much the

variability as the unpredictability. If one can somehow predict variations,

system design can take account of this and compensate. For example, we

know ahead of time that winter months bring an increase in admissions for

respiratory conditions. This is predictable variability and sensible planning

takes account of it.

TCs are intended to be less prone to the effects of unpredictable variability.

Emergency admissions, a major source of unpredictability, play little or no

part in the operation of most TCs. Booked admissions systems have been

shown to reduce patient non-attendance rates (Kipping et al, 2000). There is

also some scope for TCs to select patients thought likely to have a more

predictable stay in hospital. In addition, novel working practices in TCs are

thought likely to reduce variability between patients stays still further. All of

these factors tend to reduce unforeseen system variability, which is beneficial

from an operational viewpoint. That said, some variability in length of stay

between patients is inevitable, for example due to different treatment

requirements of patients with different diagnoses or due to within-group

variability.

This section concerns both predictable and unpredictable variability in length

of stay and discusses how knowledge regarding these can be used to assist

those planning TC services. One problem facing planners relates to estimating

Percentage of days demand exceeds capacity

0

20

40

60

80

100

10 11 12 13 14 15 16 17 18 19 20 21 22

Bed capacity

Percentage of days overloaded Expected demand = 16.8



capacity requirements to honour booked admissions for a given number of

patients with differing needs. This is inextricably linked to the question of how

one should efficiently schedule admissions from different groups of patients

taking due account of predictable variability in length of stay between the

groups.

Technical details of our mathematical modelling are given in Gallivan and

Utley (2005). Here an overview of its principles is given. We model the

operation of a single unit which treats several categories of patients, each

category having a known length of stay distribution. Different forms of

variability that are taken into account are illustrated in Figure 9. Although TCs

do not cater for emergency admissions, allowance is made for this possibility

so that the same form of model can be used to model non-TC operation.

When modelling the operation of a TC, the expected emergency admission

rate is simply set to zero.

For convenience, we regard these categories of admissions as being different

health related groups although other classifications are feasible. We assume

the unit operates a cyclically repeating pattern of booked admissions with a

planning cycle of fixed length, typically a week.

Given this simplified representation of the operation of the unit, the

admissions planning process centres on choosing the number of patients from

each health related group that are booked for admission on each day of the

planning cycle, bearing in mind that there is no particular reason why this

should be homogeneous from day to day.

Figure 9 Elements of model developed for analysis of TC operation taking

account of case mix and cyclic booking patterns

Depending on the cyclic pattern of booked admissions adopted, the mean and

the variance of the number of beds required during each day of the planning

cycle, are also both cyclic. Further, using probability theory, it is possible to

express these as exact formulae (see Gallivan and Utley, 2005 for full

details), as shown in cartoon form in Figure 10.



Figure 10 Explicit analytical expressions for the mean and variance of bed

demand dependent on cyclic pattern of booked admissions (apparent

complexity camouflages simple dependence of expressions on the decision

variables)

The reason for departing from our custom of avoiding the statement of

explicit mathematical formulae in the main text of the report is that these

formulae have particular importance. Their discovery, which was unplanned,

meant that rather more could be achieved using mathematical modelling than

was expected. The relevance of these formulae is that they express key

aspects of a hospital’s operation in very simple mathematical terms. Although

they may look complex to a non-mathematician, in view of multiple

summation symbols, in fact the algebraic form is particularly simple. These

formulae are equivalent to stating that the mean and variance of bed demand

on a particular day can both be derived in terms of linear combinations of the

numbers of different types of patients booked for admission throughout the

planning cycle. Admittedly the coefficients in these linear formulae are

somewhat fearsome, but computationally it is straightforward to calculate

what these coefficients are.

While it is mathematically pleasing that such a simple mathematical formula

should have been discovered, there are more important consequences than

aesthetics. The exciting consequence of the finding was that, since the

formulae for bed demand have a simple linear form, then they are neatly

amenable to being exploited using a range of very powerful analysis

techniques from a field of operational research called optimisation theory. Not

only that, but there are also analytical techniques related to the control of

traffic systems that can also be used to assist their analysis (Allsop, 1972).

As a consequence, even though there may be many millions of possible

admissions patterns, powerful optimisation methods can be applied to guide

this choice (Williams, 1993), as used by Adan and Vissers (2002) in relation

to scheduling hospital admissions in the case where there is no uncertainty in

patient length of stay. Computer programs have been written to compute the

mean and standard deviation of bed demand, to use these to derive estimates



of the upper 95th percentile for bed demand and to carry out optimisation.

Figure 11 summarises this approach.

Figure 11 Exploiting techniques from optimisation theory to determine booked

admission patterns that maximise reserve capacity during the week when the

number of beds available remains fixed

Again it is useful to use an example (in this case hypothetical) in order to

illustrate how these methods could be useful to those planning the delivery of

services within a TC. Consider an orthopaedic TC with 32 beds admitting

patients from two health related groups: arthroscopy and primary knee

replacement. With only two groups, this example is somewhat artificial and is

not intended to show the benefits that improved admissions scheduling might

bring in practice, more to illustrate the point of principle.

The length of stay distributions we assume are based on information taken

from the Hospital Episodes Statistics database (see www.hesonline.nhs.uk)

and have been truncated at 14 days to reflect the fact that TCs are intended

to deal only with routine caseload. We assume that to meet contractual

obligations, our hypothetical TC must on average admit 15 arthroscopy cases

and 15 knee replacement cases per week. We assume that weekend

admissions are not permitted.

As a base line case, we assume that three arthroscopy patients and three

knee replacement patients are admitted on each weekday. This is compared

to an optimal cyclic admissions schedule that smoothes out the weekly

variation in bed demand, although other performance criteria may be

preferred.

With the baseline case where admissions are distributed uniformly, the

minimum reserve capacity of 11.8 per cent occurs on Fridays, here the upper

95th percentile for bed demand is 32.9, exceeding the 32 beds available. On

the other hand, if the optimal pattern of weekly admissions (Table 5) were



adopted, then there would be less pressure on beds. The provision of 32 beds

is adequate to ensure reserve capacity of at least 21.9 per cent throughout

the week (see Figure 12), and the maximum 95th percentile has reduced by

7.9 per cent from 32.9 to 30.3 beds (see Figure 13).

Table 5 The optimum admissions pattern derived by integer programming

maximising the minimum reserve capacity during the week (the minimum

reserve capacity during the week is shown in italics)

Daily admissions by health care resource group

Weekday Arthroscopy Primary knee

Reserve Capacity (%)

Mean bed demand

95th percentile for bed demand

Monday 7 0 22.43 26.14 29.75

Tuesday 5 0 21.91 26.25 30.25

Wednesday 3 4 23.76 25.86 29.92

Thursday 0 6 25.95 25.41 29.49

Friday 0 5 22.08 26.21 30.32

Saturday 0 0 36.52 23.44 27.52

Sunday 0 0 51.34 21.14 25.05

Figure 12 Variation in reserve capacity during week comparing the baseline

(homogeneous) admission pattern with the optimised admission pattern.

0

10

20

30

40

50

60

70

M T W Th F S S

Weekday

Reserve Cappacity (%)

Homogeneous

Optimised



Figure 13 The 95th upper centile for number of beds required during days of

week comparing the baseline (homogeneous) admission pattern with the

optimised admission pattern

This simple hypothetical example points to the possibility of using such

modelling as the basis for intelligent scheduling of admissions from different

health related groups where there are systematic differences in length of

stay. This has the potential for giving operational advantages by smoothing

out bed demand throughout the planning cycle, reducing capacity needs or

making better use of existing capacity. Importantly, such efficiency gains

would cost little or nothing other than the costs of implementing a new

protocol for booking admissions.

8.4 Potential extension of modelling to the case of multiple hospital environments

The analysis methods discussed in the previous sections can be extended to

assist with another important problem: hospital planning related to the

identification of bottlenecks within the system. Here the issues go beyond the

operation of a single ward or unit and concern the progression of patients

through a succession of care processes within a hospital, each taking place

within distinct locations. An example of this is cardiothoracic surgery where

patients move from ward to operating room to a recovery room, or possibly

an intensive care environment, then back to a ward prior to discharge (see

Figure 14).

0

5

10

15

20

25

30

35

M T W Th F S S

95th centile for bed demand

Homogeneous

Optimised

Weekday



Figure 14 Representation of the patient journey through successive clinical

environments during the course of their treatment

Here, given sufficient data, one can in principle typify a patient’s journey

through the care process in terms of location/probability distributions as

illustrated in Figure 15.

In a manner similar to that used to derive the expressions discussed in the

previous section, analytical expressions can be obtained for the mean and

variance of the ‘bed demand’ in different hospital locations.

The exact form of these is complex and again, to the layman no doubt appear

to be ‘algebraic alphabet soup’, however the importance of these is that they

again give a means of applying powerful optimisation methods. In this

extended context, these would enable one not only to establish optimal

booking patterns, but also to establish where the system bottlenecks are and

the potential effects of investing in new resources within the system.

Figure 15 Location probabilities for a patient dependent on time since

admission

’

’



Developing and testing of such analytical methods for admissions and

resource planning is an exciting new research direction that has been

identified as a result of the current SDO project; however full development

and testing of the ideas goes beyond the remit of the project plan.

Fortunately, there is the opportunity to try out some of the ideas in the

context of a study funded by Great Ormond Street hospital. Also, some of

these modelling methods may form the foundation for another operational

research project funded by SDO related to restructuring services for common

mental health problems.

8.5 Modelling outpatient requirements

The final section related to modelling that may assist the operation and

planning of TCs concerns the operation of outpatient clinics. The problems

examined are actually more general and could in principle be applied in the

context of any hospital, but they are particularly appropriate to the planning

of new TCs where the planner may have to make decisions from scratch

about issues such as the number of examination rooms required, the number

of clinic sessions and how they will be assigned to rooms depending on the

availability of appropriate clinical staff and the expected patient demand for

the different specialties catered for within the TC. This is somewhat different

from the situation where outpatient plans have evolved piecemeal over many

decades.

While the operation of outpatient services does not have to deal with the

complexities of length of stay variability (although there is still some

variability in the time that an examination takes), there are still difficulties

faced by the planner in terms of a need to develop clinic schedules and room

allocations that meet a number of different requirements. Some of the key

issues that must be catered for are illustrated in Figure 16.

Figure 16 Elements contributing to modelling of outpatient scheduling and

room allocation



The problem has some elements that entail fixed constraints (for example

some clinic types require a room equipped with specialist equipment) while

others represented somewhat softer constraints (for example Sir Lancelot

Spratt prefers to work elsewhere on a Friday afternoon).

The organisation of outpatient clinics is another aspect of health care systems

that has previously been explored by operational researchers (see for

example Jackson et al, 1964; Vissers and Wijndgaard, 1979). The

mathematical difficulty of finding a reasonable clinic plan is easy to

underestimate. For example, could one not just compute all possible

schedules and see which is best?

In the context of a typical London teaching hospital, which is admittedly

larger than many TCs, assuming a planning cycle of one week, each with 10

sessions, there would be of the order of two to the power of 285 (2285)

different potential schedules. This is a number bigger than the number of

atoms in the universe. Even with modern day computers, evaluation of each

possibility separately would take longer than the age of the universe.

Research was carried out to examine the scope for applying optimisation

techniques to help to resolve this problem. Initial investigation soon identified

a way in which a technique called integer programming formulation (Williams

1993) could be used. However, this was complex and would thus require

large scale computing requirements and specialist software which hospitals

and TCs would be unlikely to have the expertise to use or the wish to buy.

Further analysis produced a modified version of the problem, greatly reducing

its complexity. In addition, the new formulation expressed the problem in a

form that has a special mathematical symmetry. Unexpectedly, this enabled

pure mathematical techniques to be applied, and it was established that a

simple optimisation method known as linear programming could be used to

solve the planning problem. The consequence of this is that, even for

relatively large scale outpatient departments, planning software to assist

clinic scheduling and capacity planning could be developed using relatively

modest computing facilities. For example, a prototype software tool was

developed making use of the Excel spreadsheet package, which is known well

by many hospital planners.

A bizarre post script to this research on outpatient scheduling was the

realisation that the analysis methods developed could be used to prove a

generalisation of a famous theorem in pure mathematics known as the

Birkhoff-Von Neumann theorem (Birkhoff, 1946; Von Neumann, 1953).

In itself, this does nothing to further the cause of health care management,

although perhaps it does serve to underline the mathematical pedigree of the

research.

Again, this research has opened up promising new topics for future study,

although resources were not available within the current grant to investigate

them further, since to do so would have distracted from the remit of the

proposal.



8.6 Summary

This section has described the use of mathematical modelling in the context

of TC operation and planning particularly in relation to issues of capacity

requirements. Due to fortunate mathematical discoveries, research has gone

much further than originally envisaged.

While the development of specific software tools has been beyond the remit

and resources of the research, a number of models have been developed that

have the potential for further development to assist with operational planning

both of TC and non-TC health environments. These include:

• a stochastic model for forecasting weekly fluctuations in bed demand and

its variance depending on rates of emergency admission, length of stay

variation, ‘do not attend’ (DNA) rates, case mix and the admissions

booking pattern

• optimisation methods for maximising reserve capacity by judicious choice

of the pattern of booked admissions

• an optimisation framework for the analysis of admissions that have

several treatment phases taking place in different parts of a hospital.

Such modelling can assist both admissions planning, the identification of

system bottlenecks and resource allocation

• mathematical methods to assist with the design and scheduling of

outpatient facilities.



Section 9 Treatment centres and the efficient use of capacity

In Section 8 we highlighted the important role of variability in determining

capacity requirements for a hospital unit. In line with the intention stated in

the original proposal, in this section we explore this notion in greater detail,

drawing a distinction between the amount of variability in a system and the

impact of that variability on capacity requirements. We then describe how the

mathematical models of capacity requirements discussed in Section 8 have

been used to assess capacity requirements in a large number of hypothetical

scenarios with a view to identifying circumstances in which the introduction of

a treatment centre to a local health economy is an efficient use of additional

capacity.

The focus of this section is very much on the structure of inpatient services

available within a local health economy rather than on how individual

treatment centres or other hospital units organise the delivery of care. With

this in mind, and solely for the purpose of the analysis presented in this

section, we view a treatment centre as a pool of capacity that differs from

other hospital units only in the categories of patient that are referred to it.

The technical detail of the work that has been done would, in our view, be

unpalatable to a general audience, so we present here an overview of this

mathematical work in terms that are hopefully comprehensible.

We begin with an explanation of the mathematical concepts that underpin

this work and the calculations that have been performed before giving an

account of how we collated the data used in these calculations. The results of

the modelling work are then presented and discussed.

9.1 One argument for introducing a treatment centre: managing variability

The folly of estimating capacity requirements based on the average demand

for beds is established in Section 8. Even if the number of admissions on any

given day is known with certainty, any variability in length of stay leads to

there being variability in the number of beds required each day. The amount

of variability in a quantity such as bed demand or length of stay is measured

in statistical terms using the so-called variance; the higher the variance, the

greater the variability.

The illustrative example given in Figure 17 shows that, if one wants to meet

demand on 95 per cent of days, different levels of variability result in

different capacity requirements, even though the average demand for beds is

the same.

While some patient-to-patient variability in length of stay is inevitable due to

intrinsic differences in the needs of patients and the response of patients to

treatment, it is often possible to identify factors that are associated with

shorter or longer stays in hospital. Such factors might include whether the

patient is an emergency admission, the procedure to be administered, the



age and fitness of the patient and any co-morbidities that the patient has

such as diabetes.

The identification of such factors offers the opportunity to separate patients

likely to have a long length of stay from those likely to have a short length of

stay. Using different pools of capacity for patient groups defined in this way

could in principle lead to a reduction in variability. Consider the length of stay

distribution shown in Figure 18. Splitting this into two separate distributions

can give a lower total variance. Hence, one argument for the introduction of a

treatment centre is that, by separating shorter stay patients from longer stay

patients, it is possible to reduce the amount of variability in the system.

Figure 17 An illustration of the importance of variability in determining capacity

requirements

0 5 10 15 20 25 30

0 5 10 15 20 25 30

0 5 10 15 20 25 30

Average demand...15 beds

(Variance...............20)

Capacity required to

meet demand 95%

of the time..............22 beds


(Variance...............10)


meet demand 95%



(Variance.................5)


meet demand 95%


Demand

Demand

Demand

Frequency

Frequency

Frequency

0 5 10 15 20 25 30

0 5 10 15 20 25 30

0 5 10 15 20 25 30


(Variance...............20)


meet demand 95%



(Variance...............10)


meet demand 95%



(Variance.................5)


meet demand 95%


Demand

Demand

Demand

Frequency

Frequency

Frequency

0 5 10 15 20 25 30

0 5 10 15 20 25 30


(Variance...............20)


meet demand 95%



(Variance...............10)


meet demand 95%



(Variance.................5)


meet demand 95%


Demand

Demand

Demand

Frequency

Frequency

Frequency



Figure 18 An illustration of how identifying patients likely to have a shorter

stay could lead to a reduction in unpredictable variability

9.2 One argument for not introducing a treatment centre

In Section 8 it was explained that for a hospital unit to operate effectively in

the presence of variability it requires more beds to be available than will be

occupied on average. The number of beds required to avoid frequent

operational emergencies is dependent on two factors. As outlined in the

previous section, the degree of variability in the system is a key determinant

of the level of capacity required. However, the overall scale of the system

considered is also important factor.

0 5 10 15 20 25 30

Variance = 20.0

0 5 10 15 20 25 30

5 10 15 20 25 30

Variance = 6.5

Variance = 7.8

Separating shorter stay

patients from longer stay

patients reduces the

variability in the system

Length of stay

Length of stay

Length of stay

Frequency

Frequency

Frequency0 5 10 15 20 25 30

Variance = 20.0

0 5 10 15 20 25 30

5 10 15 20 25 30

Variance = 6.5

Variance = 7.8

Separating shorter stay

patients from longer stay

patients reduces the

variability in the system

Length of stay

Length of stay

Length of stay

Frequency

Frequency

Frequency



The illustration shown in Figure 19 shows that, other things being equal,

capacity requirements are less if a single pool of capacity is used. In this

illustration, the total variability in demand is the same whether one or two

pools of capacity are provided, however the impact of this variability is less if

a single pool of capacity is used. In this sense, there are economies of scale

in hospital capacity planning. Hence, one argument against the introduction

of a treatment centre is that having separate pools of capacity for different

groups of patients might increase the impact on overall capacity requirements

associated with whatever variability there is in the system.

Figure 19 An illustration of why, in some circumstances, it is better to have one

large unit of capacity rather than two smaller ones

For a given average

demand and total

variability, a single

pool of capacity is

more efficient.

Demand

Frequency

Frequency


(Variance...............10)


meet demand 95%


Demand

FrequencyDemand


(Variance...............20)


meet demand 95%



(Variance...............10)


meet demand 95%


For a given average

demand and total

variability, a single

pool of capacity is

more efficient.

Demand

Frequency

Frequency


(Variance...............10)


meet demand 95%


Demand

FrequencyDemand


(Variance...............20)


meet demand 95%



(Variance...............10)


meet demand 95%




9.3 Comparing capacity requirements with and without a treatment centre

There is seemingly a tension between the two arguments presented above.

On the one hand, the introduction of a treatment centres offers the

opportunity to reduce the total variability in demand for beds by using

separate pools of capacity for groups of patient that differ in terms of their

length of stay characteristics; on the other hand having separate pools of

capacity runs contrary to the economies of scale in capacity planning and may

increase the impact of variability in demand on capacity requirements of

variability in demand.

To explore the interplay between these two effects, we have adapted one of

the models of capacity requirements introduced in the previous section. This

has been done by constructing a large number of hypothetical scenarios. For

each scenario we have estimated the capacity required to meet demand 95

per cent of the time in all units (TC or non-TC) for two distinct configurations

of inpatient services: one in which there is no separation of shorter stay

patients from longer stay patients and one in which shorter stay patients are

referred to a treatment centre. An illustration of one such scenario is given in

Figure 20.

To give one measure of the relative efficiency of the two service

configurations we then calculate ρ, the ratio of the capacity requirements with

a treatment centre to the capacity requirements without a treatment centre

(see Figure 21). If ρ is equal to 1, the implication is that capacity

requirements are the same regardless of whether a TC is introduced to a local

health economy or not. A value of ρ less than one suggests that the

introduction of a TC would lead to a more efficient use of capacity across a

local heath economy as a whole; a value greater than one suggests that the

introduction of a TC would lead to a less efficient use of capacity across the

local heath economy.

Figure 20 Two configurations of inpatient services within a local health

economy, in one of which a treatment centre delivers services to those patients

identified as likely to have a shorter hospital stay

Hospital 1

Hospital 1

TC

Hospital 2

Hospital 2

Hospital 1Hospital 1


TCTC





Figure 21 The modelling work has involved comparing the capacity

requirements associated with two configurations of inpatient services (with or

without a treatment centre) in a large number of hypothetical scenarios

In taking the workload as fixed and determining which of two configurations

of service is the most efficient for dealing with this throughput, there is an

implicit assumption that greater throughput could be achieved with the more

efficient configuration.

9.3.1 The importance of taking a ‘whole system’ view

It is important to note at this stage that our focus is on the impact of a TC on

the efficient use of capacity within the system as a whole. Given the

characteristics of the patients referred to a TC, it is likely that greater

efficiency in the use of capacity can be achieved within a TC environment

than in a non-TC environment. However, it is entirely possible that a TC could

be extremely efficient in terms of capacity use and yet have a detrimental

effect on the efficient use of capacity within the local health economy that it

serves as a whole.

9.4 Modelling the intelligent selection of patients for referral to a treatment centre

One defining characteristic of the scenarios that have been evaluated is the

extent to which the patient population can be separated into longer-stay

patients and shorter-stay patients, with the shorter-stay patients deemed

suitable for referral to a treatment centre. Whereas the number of admissions

per day, for example, is a simple concept, there is no simple way of

characterising the degree of success in such ‘intelligent’ selection of patients.

For now, we discuss different ways of separating the overall patient

population into two groups of equal size. In the worst case, the patient

population identified as likely to have shorter stays (and referred to a

treatment centre) would in fact have exactly the same length of stay

characteristics as those patients identified as likely to have longer stays

(Figure 22a). The best possible selection of patients would result in every

patient identified as likely to have a shorter stay actually having a shorter

hospital stay than every patient in the group identified as likely to have a

longer stay (Figure 22b).

ρ =

Capacity requirements of

Hospital 1 Hospital 2


TCHospital 1 Hospital 2

ρ =


Hospital 1 Hospital 2Hospital 1Hospital 1 Hospital 2Hospital 2


TCHospital 1 Hospital 2TCTCHospital 1Hospital 1 Hospital 2Hospital 2



Figure 22 The two extreme cases in which identifying patients likely to have a

shorter stay is (A) entirely unsuccessful or (B) entirely successful

(A) Worst case

(B) Best case

In reality, the success achieved in identifying shorter-stay patients for referral

to a TC is likely to fall between these two extremes. To define the different

hypothetical scenarios that have been evaluated as part of this project, we

Cost of stay

Frequency

Cost of stay

Frequency

Cost of stay)

Frequency

Refer to TC

Refer to hospital

Cost of stay

Frequency

Cost of stay

Frequency

Cost of stay

Frequency

Cost of stay)

Frequency

Cost of stay)

Frequency

Refer to TC

Refer to hospital

Length of stay (days)

Frequency


Frequency


Frequency

Refer to TC

Refer to hospital


Frequency


Frequency


Frequency


Frequency


Frequency

Refer to TC

Refer to hospital



used a mathematical function that has a parameter α, different values of

which represented different degrees of success in identifying shorter-stay

patients. The illustration shown in Figure 23 shows, for a hypothetical length

of stay distribution, the separation between short-stay patients and longer-

stay patients represented by α = 3.

Figure 23 Modelling patient selection. An illustration of how we modelled the

degree of success achieved in separating shorter stay patients from longer stay

patients

9.4.1 The interplay between economies of scale and

patient selection

In this section we illustrate the analysis that has been performed in the

context of the simplest set of scenarios that were constructed, in which there

is just one non-TC hospital site. Example results for such a set of scenarios

are shown in Figure 24. Each tile in this chart represents an estimate of the

impact of introducing a TC on capacity requirements for a given combination

of the scale of the non-TC hospital (the number of daily admissions in the

absence of a treatment centre) and ρ, the degree of success in identifying

patients likely to have a shorter stay. The colour of each tile indicates the

value of α where, as stated previously, a value of ρ less than one indicates

that a TC would have a positive impact on the efficient use of capacity within

the local health economy.

Modelling patient selection

Refer to TC

Refer to hospital

Length of stay

We used a parameterised

mathematical function to represent the

degree to which intelligent selection of

patients can be achieved.

Frequency

Length of stay

% referred to hospital

50%

100%

Refer to TC

Refer to hospital

Length of stay

We used a parameterised

mathematical function to represent the

degree to which intelligent selection of

patients can be achieved.

Frequency

Length of stay

% referred to hospital

50%

100%



Figure 24 Example results showing the impact of introducing a treatment

centre on the efficiency with which capacity is used in a large number of

hypothetical scenarios

It is apparent from these example results that, in this set of scenarios, there

is a trade-off between the reduction in variance achieved with patient

selection and the economies of scale. Moving from left to right across Figure

24, the greater the degree of success in identifying patients likely to have a

shorter stay (α), the more beneficial the impact of a TC. However, for a given

value of α, the higher the number of daily admissions the less beneficial

introduction of a TC. Note that the nature of the interplay between the

number of daily elective admissions and α is specific to the length of stay

distribution of the patient population considered. This is discussed in more

detail later in this section.

9.5 Other factors that may influence the relative efficiency of different service configurations

In addition to the effects of the intelligent selection of patients and the

economies of scale discussed in Section 9.4.1, there are a number of other

factors that may influence whether or not the introduction of a TC has a

beneficial impact on the efficient use of capacity within a local health

economy. The other factors that have been used to define the scenarios

evaluated in this study are given below.

Level of emergency admissions as a proportion of elective admissions

As the introduction of a TC is intended to separate routine elective services

from more complex elective and emergency work, the level of emergency

admissions among the patient population concerned is clearly an important

Worseρ > 1

Marginally better0.975 < ρ = 1

Better0.95 < ρ = 0.975

Much betterρ < 0.95

αααα (degree of success in identifying shorter stay patients)

N (number of daily admissions)

2

10

4

6

8

12

14

16

18

20

1 3 5 9 11 13 15 17 19 21 23

Efficiency of capacity use

if a TC is introduced

Worseρ > 1

Marginally better0.975 < ρ = 1

Better0.95 < ρ = 0.975

Much betterρ < 0.95

αααα (degree of success in identifying shorter stay patients)

N (number of daily admissions)

2

10

4

6

8

12

14

16

18

20

1 3 5 9 11 13 15 17 19 21 231 3 5 9 11 13 15 17 19 21 23

Efficiency of capacity use

if a TC is introduced



consideration. In addition to increasing average demand, emergency

admissions increase the amount of unpredictable variability in the system. It

is likely then, that for the same level of elective admissions, the interplay

between patient selection and economies of scale will have different

characteristics dependent on the level of emergency admissions. In the

scenarios that have been evaluated, the average rate of emergency

admissions was taken to be a given percentage of the daily rate of elective

admissions (zero, 10 or 20 per cent).

Number of non-TC hospitals within the catchment area of a single TC

The example results shown at Figure 24 are for the simplest set of scenarios

where, if introduced, a TC would only accept referrals that would otherwise be

made to a single non-TC hospital. However, in some local health economies, a

TC might accept patients that would otherwise have attended one of a

number of non-TC hospitals, potentially increasing the average demand at the

TC and affecting the interplay between economies of scale and patient

selection. Scenarios were evaluated where, if introduced, a TC would provide

services to a catchment area shared by one, three or five non-TC hospitals.

For the sake of simplicity, within each scenario all non-TC hospitals were

considered to be identical.

Length of stay distribution for patient population

From Figure 24, it is clear that the impact of introducing a TC depends on the

degree of success achieved in identifying patients likely to have a shorter

stay. Another potentially important factor is the overall distribution of length

of stay among the patient population considered, as this influences average

demand and the total variability in demand in the absence of any intelligent

selection of patients. We evaluated scenarios in which the patient population

concerned had the length of stay characteristics of urological surgery

patients, general surgery patients and orthopaedic surgery patients.

Overall proportion of patients that would be referred to the TC

The results shown at Figure 24 are for a set of scenarios in which half of all

the elective patients within the patient population concerned (the half

identified as likely to have shorter length of stay) are referred to the TC.

Changing this proportion changes both the number of patients referred to

each setting and the length of stay characteristics of patients referred to each

setting. We evaluated sets of scenarios where one quarter, one half or three

quarters of all elective patients were referred to the TC.

9.6 Data collation

As mentioned in the previous section, one of the defining characteristics of

each scenario that was constructed as part of the modelling work was the

length of stay distribution for the patient population concerned. In this section

we present the different length of stay distributions that were used in our

calculations.

We obtained data concerning all admissions to hospital trusts in England for

the years 2001/2, 2002/3 and 2003/4 from Hospital Episode Statistics



(Department of Health, 2005e). This dataset contained information about the

patient’s admission method (such as elective or emergency), specialty (in

terms of health care resource group), admission date and discharge date. We

then extracted all urology, orthopaedic and general surgery patients from the

dataset. Table 6 indicates the number of patient entries that were extracted:

Table 6 Number of patient entries extracted from the Hospital Episode Statistics

data, for patients in urology, orthopaedic or general surgery specialties

Number of entries Data set Date range

Total Extracted

2001/2 April 2001 – March 2002 12,973,256 2,205,349

2002/3 April 2002 – March 2003 13,442,308 3,477,514

2003/4 April 2003 – March 2004 14,133,974 3,957,997

Table 7 shows the proportion of records which had incomplete length of stay

information and which therefore could not be used within our analysis.

Patients that stayed in hospital for less than one day were assumed to be day

cases rather than inpatients and these records were not used in our analysis

of capacity requirements for inpatient services. The length of stay distribution

for elective inpatients was constructed for each specialty for each of the three

years using a log-linear scale (not shown). On inspection of these graphs, we

considered that it was reasonable to take the 2002/3 data set as

representative of the length of stay distribution for the entire three year

period.

Table 7 Proportion of day case patients, patients staying at least one day and

patients with incomplete length of stay information in each year and specialty

category


Specialty

Year

Number Not available / Incomplete 0 1 or more

2001/2 81,316 0.61% 80.19% 19.19%

2002/3 406,376 3.51% 76.12% 20.37%

Urology

2003/4 366,924 3.59% 76.78% 19.63%

2001/2 36,142 0.91% 37.39% 61.70%

2002/3 217,385 7.05% 38.12% 54.84%

Orthopaedics

2003/4 192,786 6.90% 37.12% 55.98%

2001/2 94,116 2.17% 63.20% 34.63%

2002/3 428,385 10.49% 58.13% 31.38%

General surgery

2003/4 316,078 10.26% 56.88% 32.86%

Length of stay scenarios: elective admissions

In the hypothetical scenarios that were constructed, three length of stay

distributions were used. For each of these distributions, in order to limit the

tail of the distribution, patients staying for more than 128 days were assumed

to stay exactly 128 days. Figures 25, 26 and 27 show the distributions used



to represent the length of stay characteristics of elective urology, orthopaedic

and general surgery patients.

Figure 25 Distribution of length of stay for elective urology patients that stayed

at least one night in hospital

Figure 26 Distribution of length of stay for elective orthopaedic surgery

patients that stayed at least one night in hospital

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0 10 20 30 40 50 60 70 80 90 100 110 120


Probability

0

0.05

0.1

0.15

0.2

0.25

0 10 20 30 40 50 60 70 80 90 100 110 120


Probability



Figure 27 Distribution of length of stay for elective general surgery patients

who stayed at least one night in hospital

Source for Figures 25, 26 and 27: Hospital Episode Statistics 2002/3

Length of stay for emergency admissions

From the 2002/3 returns to HES, we also extracted separate length of stay

distributions for emergency and transfer patients for each specialty. These

distributions are shown in Figures 28, 29 and 30.

Figure 28 Distribution of length of stay for urology patients admitted as an

emergency that stayed at least one night in hospital

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

0 10 20 30 40 50 60 70 80 90 100 110 120


Probability

0

0.05

0.1

0.15

0.2

0.25

0 10 20 30 40 50 60 70 80 90 100 110 120


Probability



Figure 29 Distribution of length of stay for orthopaedic surgery patients

admitted as an emergency that stayed at least one night in hospital

Figure 30 Distribution of length of stay for general surgery patients admitted as

an emergency that stayed at least one night in hospital

0

0.05

0.1

0.15

0.2

0.25

0 10 20 30 40 50 60 70 80 90 100 110 120


Probability

0

0.05

0.1

0.15

0.2

0.25

0 10 20 30 40 50 60 70 80 90 100 110 120


Probability



9.7 Results

With three patient populations, three different values for the proportion of

elective patients referred to the TC, three different values for the number of

non-TC hospitals and three different levels of emergency admissions, 81

(3x3x3x3) sets of scenarios such as that shown in Figure 24 were evaluated;

this corresponds to a total of approximately 880 distinct scenarios. Clearly the

space available here prohibits us from presenting the results of every

scenario. We present here results for a selection of 18 sets of scenarios.

Figure 31 shows results for nine sets of scenarios concerning the introduction

of a TC to deliver urological surgery services.

Figure 31 The impact of the introduction of a treatment centre on the efficient

use of capacity for a large number of hypothetical scenarios related to the

delivery of inpatient urology services

In all of these scenarios, half of all elective urological surgery patients are

referred to the TC. Each small chart within Figure 31 is analogous to Figure

24, showing the impact of a TC on capacity requirements depending on N (the

number of daily booked elective admissions to each non-TC site if no TC is



introduced) and α (the degree of success achieved in intelligent patient

selection). The top row of three charts relates to scenarios in which the TC is

introduced to a local health economy with just one non-TC hospital, with the

level of emergency admissions increasing from 0 per cent (leftmost chart) to

20 per cent (rightmost chart). The middle row relates to scenarios in which

the TC is introduced to a local health economy with three non-TC hospitals.

The results in the bottom row relate to scenarios in which there are five non-

TC hospitals. Figure 32 shows results for the equivalent scenarios concerning

the introduction of a TC to deliver orthopaedic surgical services.


use of capacity for a large number of hypothetical scenarios related to the

delivery of inpatient orthopaedic services



9.8 Discussion

These figures display a number of interesting features. Firstly it can be seen

that, the higher the level of emergency admissions, the less beneficial the

impact of a TC on the capacity requirements for the local health economy as a

whole. Secondly, a key finding is that the more non-TC hospitals that refer

patients to a TC, the more beneficial the impact of a TC on capacity

requirements. Put simply, this has the effect of increasing average demand at

the TC and economies of scale at the TC counter the deleterious effect of

having an extra unit of capacity. These two effects are seen for general

surgery patients also (results not shown).

Another finding of interest is that the interplay between the daily number of

elective admissions to each non-TC in the absence of a treatment centre and

patient selection is more complicated than a simple trade-off and depends on

the length of stay distribution for the patient group concerned. This is for two

reasons: the mean length of stay influences the average demand for beds

within the system and hence the impact of variability; the length of stay

distribution determines the reduction of variability associated with a particular

value of α. That said, it is generally the case that the introduction of a TC had

a more beneficial impact in scenarios where greater success is achieved in

identifying shorter stay patients.

The scenarios in which the introduction of a TC seems to offer most

theoretical benefits are those in which the TC serves a catchment area where

there are a large number of non-TC hospitals, where there is considerable

success in identifying and referring to the TC patients that are likely to have a

shorter length of stay and for which there is little emergency demand among

the relevant patient population as a whole. (Such scenarios are represented

by the right hand side of the bottom left ‘tiles’ in Figures 31 and 32.)

9.8.1 Aside: what if the treatment centre admitted the

longer stay patients?

One of the great advantages of mathematical modelling as a research tool is

that one can explore extreme or perhaps infeasible scenarios to see whether

the results provide insight into the key dynamics of the system. To this end,

we constructed additional scenarios in which, rather than admit patients

requiring routine elective procedures, the TC took those elective patients

identified as likely to have longer stays; in these scenarios the non-TC

hospitals admitted emergency patients and those identified as likely to have

shorter length of stay. The results for orthopaedic surgery patients are shown

in Figure 33. It can be seen that, from the narrow perspective considered

within in this modelling work, the impact of introducing a TC is particularly

beneficial in some of these scenarios, particularly those in which there is

more than one non-TC hospital. This is because there would be greater

economies of scale in pooling those patients that show longer (and typically

more variable) length of stay. While clearly at odds with the ethos of TCs,

from the point of view of making the most efficient use of capacity, it would

make better sense to centralise the delivery of services for patients likely to

have a longer stay in hospital. This is not a new notion (see for example



Bowers and Mould, 2002), indeed similar thinking underpinned the creation of

sanatoria for tuberculosis in the last century.


use of capacity for inpatient orthopaedic services

Note: In these scenarios, long stay patients are referred to the TC while short stay and

emergency patients remain in the non-TC hospitals

9.8.2 Caveats

It is important to note that the mathematical modelling that has been

conducted was intentionally limited in scope and a number of caveats should

be borne in mind when interpreting the results presented here.

The mathematical modelling aspect of this study was intended to inform a

theoretical evaluation of TCs as a mode of service delivery from a narrow

perspective concerning the impact of the structural changes to service

delivery within a local health economy associated with the introduction of a

TC on the efficient use of capacity within the whole system. There is an

implicit assumption in our work that increasing capacity available within the



local non-TC hospitals is a viable alternative to increasing capacity via the

introduction of a TC. In some urban areas this may not be the case.

The scenarios constructed differed only in the structure and organisation of

service delivery. Figure 34 illustrates the mechanisms by which TCs could

potentially improve the efficient use of capacity within a local health

economy. The modelling work presented in this section has covered two of

the five potential mechanisms identified. The potential for the intelligent

scheduling of elective admissions is discussed in Section 8. Importantly, no

account was taken of the possibility that a given patient would stay in

hospital for a shorter period of time if treated within a TC than in a non-TC

environment. Genuine reduction in length of stay within TCs (as opposed to

apparent reduction in length of stay due to patient selection) would clearly

improve the prospects of a TC in improving the efficient use of capacity.

Although beyond the scope of the current project, the methods used in this

research could be extended to evaluate scenarios that incorporate this

possibility.

Another feature of hospital operation not considered within this work is that

of theatre utilisation. The work of Mould et al (2002) suggests that separating

routine elective work from more complex elective work and emergency

services is likely to have a detrimental effect on theatre utilisation within the

non-TC sites.

Figure 34 Mechanisms by which the introduction of TCs might improve the

efficient use of capacity

9.9 Summary

The construction and evaluation of a large number of hypothetical scenarios

has enabled us to identify circumstances in which the introduction of a TC

might improve the efficiency with which capacity is utilised within a local

health economy. The circumstances under which the introduction of a TC does

seem to offer such theoretical benefits are those where the TC serves a

catchment area where there are a large number of non-TC hospitals and

where there is considerable success in identifying and referring to the TC

patients that are likely to have a shorter length of stay.

Intelligent Scheduling of

Elective Admissions

Intelligent Selection of

Patients for TCs

Economies of ScaleGains in efficiency for

whole system?

Structure and

organisation of service

Reducing Length of Stay

Reducing Variability in Length of Stay

Management

of patients

Intelligent Scheduling of

Elective Admissions

Intelligent Selection of

Patients for TCs

Economies of ScaleGains in efficiency for

whole system?

Structure and

organisation of service

Reducing Length of Stay

Reducing Variability in Length of Stay

Management

of patients



Another finding of this work is that, in the absence of genuine length of stay

reduction within TC environments, there are circumstances in which the

introduction of a TC may have a negative impact on the efficient use of

capacity within the local health economy as a whole. These circumstances

include the delivery of services where the proportion of all admissions that

are emergency cases is significant and in which, for whatever reason, it is not

possible to identify, at the point of referral, patients likely to have a shorter

length of stay.

It is of interest that, from the perspective of improving efficiency in capacity

use across a local health economy as a whole, the key determinant of success

seems to be a number of non-TC trusts co-operating with primary care to

ensure that, for a given procedure, patients identified as likely to have a

shorter length of stay are referred to the TC while they admit a much more

challenging case load. Whether such co-operation is likely given the

competitive environment that hospitals find themselves operating in is

questionable.



Section 10 Conclusions and discussion of the implications for policy, concepts, practice and research

Our three-year research study examining TCs as organisational innovations in

the NHS set out to achieve two broad objectives:

1 to conduct a technical evaluation (incorporating mathematical modelling)

both of the concept and actual impact of TCs as an innovative way of

delivering health care within the NHS

2 to study – using qualitative methods – the organisational and social

factors associated with the development of TCs in order to demonstrate

how these impact upon the implementation process and its

organisational outcome.

Having presented our detailed findings in Sections 3 to 9, we conclude with a

brief summary of our main findings, followed by a discussion of the

implications of our research for future policy, practice, and research with

regard to organisational innovation and service development in the NHS.

10.1 Conclusions

When the NHS Plan was launched in 2000, TCs were a promising

organisational innovation based on practice exemplars, rather than research

evidence; but their political time had come. By 2003, as our study

commenced, it was clear that strong political and organisational drivers were

spearheading their rapid diffusion into the NHS. But the innovation was part

of a much wider government drive to modernise the NHS. Accordingly the TCs

were launched into the dynamic and complex organisational milieu of an NHS

in transformation – a milieu in which multiple parallel changes, all likely to

impact on the fledgling TCs, were occurring with great speed. These included

a programme of independent (private) sector TCs as part of a wider

governmental push towards involvement of the private sector in the delivery

of care, presaged in the NHS Plan; the introduction of Payment by Results, a

new system for reimbursement; and the simultaneous introduction of the

Patient Choice initiative and the Choose and Book programme. As a result,

our study became the story not of a single innovation and its impact on

health services, but the organisational response of one emerging sector of

care in a maelstrom of modernisation.

Despite this welter of modernising initiatives, the central programme for

developing TCs gave an opportunity for local developments to take place that

– while they often differed greatly from the ideal TC as envisaged by the

Department of Health and the Government - contained many of the intended

principles. Thus the central programme allowed, as it were, headroom for

local managers to implement their own desired innovations. While the

Department of Health might not always be able to make things happen as

they would have liked, the central programme had the effect of letting things

happen locally that might otherwise not have occurred. The centre also



created structures intended to help the local innovators – not only directly

with such initiatives as the Modernisation Agency’s learning events and advice

(including some elementary design rules for this particular type of

organisational innovation), but also by providing capital funding, a direct

stimulus with associated performance expectations.

The cultures of our eight sample sites that chose to open TCs were all very

different from each other. We found a range of management styles,

aspirations, relationships and pressures. However, the one factor which

united them was the sense that this particular organisational change was

timely and necessary, and alongside this we found a ‘can do’ mentality and

the presence of some core ‘champions’ who were keen to implement this

innovation. The nascent TCs’ relationships with their external milieu – the

local health economy including the host trust, the PCT, the SHA, neighbouring

trusts, and their own internal staff – also showed a wide range of

relationships that appeared to run along a continuum from hostility and

conflict with most of the major stakeholders in their external milieu, through

to much more harmonious and constructive partnerships with the major

players, with examples of most points somewhere in between these

extremes.

The local organisations that took up the challenge of establishing a TC did so

for a wide variety of reasons. In addition to the generally favourable policy

environment, local motivations to open a TC were often rooted in local history

and context (for example pressure to find new capacity to treat patients on

their own or other hospitals’ waiting lists, a stalled plan to relocate surgical

services or open a day-surgery unit, the need to find a use for an underused

hospital building, the chance to engineer changes in local professional

influence, and so on), which conspired to drive each local initiative forward.

While to some extent these motivating factors were unique to each of our

sites, some common features emerged.

Firstly, the people. The decision to apply for TC funding inevitably resulted

from the resolution of a number of often conflicting views (which we have

referred to as contests of meaning). These were clearly influenced by key


external milieus of their organisations. For example there may have been –

and usually were – idealists who saw the TC as a chance to improve patient

care. But there were nearly always sceptics who saw it as yet another fad,

opportunists who wanted to secure the funding to develop a new service that

was in any case much needed, and pragmatists who wanted to do whatever

seemed most likely to improve the service with minimum fuss. Even where

there was consensus among those with the power to make the final decision,

there were always discrepancies about their underlying motivations,

rationales and intended outcomes, resulting in evolving and constantly

negotiated clusters of decisions that gradually emerged as something

approaching (at least) some of their initial visions of a TC.

A second unifying thread in the various reasons why these sites developed

TCs is the sense that they wanted to bring about improvements – to ‘improve

quality’, to ‘improve quantity’ and/or to ‘improve kudos’. In improving quality

some sites prioritised patient-focused approaches to care or ‘modernising’

patient processes. This included the fundamental reform of traditional clinical

practices and transformations in skill-mix. In improving quantity the case



studies were hoping to increase capacity, throughput and activity, and in this

they were tightly coupled to a performance agenda set down by the

Department of Health, which was concerned with reducing waiting times and

increasing activity. In improving kudos for the organisation (or for individuals

within it) the sites were hoping their TC would make their organisation more

competitive, or at the very least to prevent them falling behind and becoming

uncompetitive. Some sites also used ties with external stakeholders (SHAs,

the Modernisation Agency or the Department of Health) as a way for the TC

help to improve the profile of the wider trust (or of key personnel within it).

Thirdly, all our sites experienced a variety of problems related to imprecise

planning, financial setbacks and (usually) overcapacity, and all experienced

some degree of evanescence of some of the original motivators for change,

such as the principle of nurse-led care or other shifts in professional roles. For

a variety of reasons, almost none of the TCs was able to plan and predict with

any consistency or precision even such basic parameters as the numbers and

types of patients they would treat. The way that the TC fared once it had

opened depended partly on the changing state of the local health economy,

which was shifting constantly in the maelstrom of central initiatives and the

very varied local responses to them. Many of these had not only indirect but

direct impacts on the ways the new TCs functioned (for example the financial

incentives – or disincentives – for local trusts to send them patients). The

outcome depended on how the managers of the TCs were able to respond to

this rapidly changing environment, which in turn depended on the

relationships they had with key stakeholders in their local health economies.

In this respect the TC managers and those of their host trust were, by their

responses, enacting the environment with which they subsequently had to

cope (for example, by the kinds of competitive or collaborative relationships

they established with key local stakeholders).

Despite the turmoil, however, there was often perceived to be an impact on

patient flows – such as increased throughput and a decrease in waiting lists –

and significant changes in the quality of the care that patients received.

These included pre-operative assessment done by nurses via a questionnaire,

a nurse-led clinical pathway about which patients were fully informed before

arriving at hospital, well-honed individual care pathways with key milestones

(based albeit sometimes controversially on US models), case managers in

charge of discharge planning, PCTs providing planned intermediate care, and

considerable redesign of the workforce and the physical environment in order

to accomplish these new ways of working. But often the eventual changes

were relatively superficial (‘first order’ rather than ‘second order’

transformation). By the end of the three-year study, three of the eight sample

sites remained (partially) identified with the NHS programme, one had closed,

one had been bought out by a private health care provider and three were at

some stage of becoming linked with the independent sector. Only one of

these appeared to have weathered the storm by emerging as a stand-alone

TC that closely followed the original exemplar of the policy model of what an

NHS-run TC should be.

Finally, while we have shown that it is possible mathematically to model ways

to optimise patient flows and bed capacity, the planning capacity of NHS

management in the frenetic environment in which TCs were being developed

meant that such considerations appeared much less relevant than perhaps



they ought to have been. It was possible through our mathematical modelling

to show, for example, that there were some circumstances under which the

introduction of a TC might be predicted to offer little if any benefit to the local

health economy, and indeed that serious problems of overcapacity might

result (as in the event it did do, in just the kinds of sites that the model

predicted). Yet despite the apparent weight of such logical argument, the

local political and clinical context, motivations and environments would have

made it impossible for such a finding to carry any weight in the complex

evolution of plans, negotiations and implementation.

10.2 The ‘innovation journey’

The model of the ‘innovation journey’ has been helpful in analysing our data

(Van de Ven et al 1999). Van de Ven and colleagues in their classic 17-year

Minnesota Innovation Research Programme, which studied 14 innovations

developed in a variety of organisations mostly in the commercial sector,

observed that innovations never underwent a linear development, but took

seemingly unexpected twists and turns in a complicated and apparently

unpredictable journey from their inception to their final outcome of

implementation or abandonment. They explored whether this might be more

than just random and contingent, but rather the result of a ‘non-linear

dynamic system’; in other words, whether one might be able to identify the

components in both the innovation and its environment that might help one

predict, and therefore perhaps control, those twists and turns. As we did with

the TCs, they found fault with the conventional wisdom that an innovation

was a stable entity, maintained and developed over time, in which key

parties, having developed a consensus about the (largely technical) potential

of the innovation, carry it through the stages of its development, testing,

adoption and diffusion. Their fieldwork revealed a very different picture, one

which resonates with our own findings in Sections 4 to 7 above:

As the developmental processes unfolded, we saw innovation ideas proliferate

into many ideas. There was not only invention but reinvention; some ideas were

discarded as others were reborn. Many people were involved, but most only

partially: they were distracted by busy schedules as they performed other

unrelated roles. The network of stakeholders involved in transactions was

constantly revised. This ‘fuzzy set’ epitomises the general environment for the

innovation as multiple environments are ‘enacted’ (Weick, 1979) by various

parties to the innovation. Rather than a simple, unitary, and progressive path,

we recorded multiple tracks and spin-offs, some that were related and co-

ordinated and others that were not… The discrete identity of the innovation

became blurred as the new and the old were integrated

(Van de Ven, 1999; pp.8-9)

The ‘innovation journey’ as Van de Ven and colleagues depict it, has a

number of components that – while not necessarily happening in an orderly

sequence – take it from an initiation period, through a development period, to

implementation or termination. It was possible to detect a similar pattern in

the TC journeys. One can see an initiation period in which there was gestation

(Section 2) during which the Government formulated the programme to help

deal with waiting time and waiting list reductions, patient-centred care and

the need to modernise service organisation and delivery, and allocated extra

central funding to achieve this. There was also local gestation, in which

chronic unfulfilled aspirations to recreate the organisation or change services



had been growing. A vital component of the ‘journey’ was what Van de Ven

and colleagues call the ‘shock’ (the sudden stimulus that catalyses the

inception of the innovation). At the local trust for example, this might be the

sudden availability of new capital funds for something new called a ‘treatment

centre’ coupled with critical events stressing the need to rebuild or revamp

the organisation (for example increased competition; failure to meet local

waiting time targets; extreme financial deficit in host organisations, or some

existential or identity crisis that the trust was undergoing.) Thus local and

national gestation factors would be transformed by the ‘shock’ into the

opportunity for a new TC. The next key component is the planning– about

which we will say much more below – which nationally involved largely

rational planning by the Department of Health and Modernisation Agency, but

which evolved as new policies were devised. Locally, planning often consisted

of business plans hastily pulled together to satisfy local and national decision

makers (equivalent to Van de Ven’s ‘resource controllers’) but not necessarily

to act as workable blueprints – another feature of the innovation journey

described in the Minnesota study. And, as in their study, the TC plans were

constantly forced to adapt in reaction to national and local policy shifts.

The components of Van de Ven et al’s second period, the ‘development

period’, comprise:

• a proliferation of varying ideas and activities (which describes very well

the diversity that we found)

• setbacks and mistakes (as is clearly evident in Section 6)

• shifts in the success criteria (for example the proportion of private care or

the changes in financial arrangements)

• changes in key personnel and key external organisations (most of our

TCs were characterised by rapid turnover of key management staff both

internally and changes among key external players)

• the creation of a trans-organisational community infrastructure of

innovators (for example NHS Elect).

Finally, during the implementation or termination period, their model

describes how the innovation links the old with the new (note for example

how in Section 6 we see that nearly all of the TCs were reabsorbed into their

host trusts); a reinvention of the innovation to fit the local situation (a main

theme of our findings); and finally the termination of the innovation as it

either becomes part of the mainstream or – as at Site F – is closed.

This very brief exegesis of the ‘innovation journey’ model shows how readily it

can be applied to the organisational innovation of TCs in the health service.

Despite the model having been derived mainly from studying the

development of technical innovations in the commercial sector, it helps make

sense of the complexity, diversity and apparent disorder that we found in our

fieldwork. And it shows that our findings were in keeping with findings from

that classic study of innovation. But in addition, we found several key aspects

of the process that figured prominently in the TC story, which are particular

features of the NHS and require further elucidation. These include:

• the general policy environment, which is now moving ostensibly away

from the top-down, target-led environment that pertained during our

study, and more towards innovation based on local initiative



• the implications of the contests of meaning of the innovation of TCs at

the different levels of the NHS

• the nature of planning and decision making in a volatile policy

environment

• the possible place of ‘design rules’ in the innovation process

• the place of mathematical modelling in a frenetic planning environment.

We discuss each of these below before ending with a review of the TC

innovation programme against the template first put forward by Greenhalgh

and colleagues (who include two of the present authors, Paul Bate and Glenn

Robert), in an SDO-funded project in 2005 (Greenhalgh, et al 2005). First

however, we list some possible implications of our findings for the NHS.

10.3 Policy implications of the research

In this section we discuss some of the broader policy issues that place our

research findings in the likely future contexts of UK health care; we focus in

particular upon the ‘new’ model of policy implementation that is currently

emerging. One particular facet of this model is an apparent shift away from

‘top-down targets’ to a ‘local innovation and incentive-led’ framework, and we

consider the implications of this change for organisational innovations such as

TCs.

10.3.1 The concept of innovation within the ‘new’

Government framework: from top-down drivers to local

incentives Beyond the specific policy initiatives described in Section 5 there has also

been a shift (or at least an espoused shift) in the broader underlying

assumptions and approach to policy implementation in the NHS. The NHS

Modernisation Agency, initially responsible for implementing the TC

Programme nationally, has been closed down, and we are learning more by

the day about a ‘new’ Department of Health, committed to moving away from

the NHS from a directive, top-down, target-driven organisation based on

performance management and the vertical pressures of hierarchical line

management (‘model 1’). Although this constrictive model has been described

by Hoque and colleagues (2004), who were studying a foundation hospital

trust, as leaving very little room for managerial autonomy despite all the

rhetoric about devolution, our case sites were mostly able to find considerable

local latitude while still apparently conforming to central diktat (see Sections

4-7 above, and Pope and Robert et al, 2006). Be that as it may, the current

policy seems to denote a transformation to a combination or hybrid of two

further models:

a the lateral pressures of the commissioners in a commissioner-provider

organisation, where the vertical lines are loosened and performance

management becomes contract management (‘model 2’)

b a bottom-up model based on competition between providers and

pressures upwards from patients as choice becomes a major incentive for

innovation and improvement (‘model 3’).

Greener (2004a; p.673) attributes the latter to a phased shift in New Labour

policy since 1997, which has seen the chosen ‘driver for change’ moving from



‘quality’ through ‘performance’ to ‘choice’, the most recent of these reflecting

a:

…far more explicit model of health consumerism in place than ever before,

placing Patient Choice before even medical expertise, and placing a serious

challenge to the latter. Patients have gone from being passive recipients of

health policy, to being expected to drive change on behalf of the state.

(Greener, 2004a)

The recent NHS Operating Framework for 2006/7 confirmed the change of

‘driver’ from ‘targets-driven’ to ‘incentives-driven’, expressing it thus:

…[a commitment to] reform the health system fundamentally, so that change is

driven more by incentives to respond to patients than by top-down target

setting… old methods of top-down performance management will not be

sufficient to deliver this

(Department of Health, 2006b; pp.2-3)

Indeed, so as to leave no doubt, the Department of Health proceeded to

reinforce this comment with a striking graphic which made explicit reference

to the idea of ‘local innovation’ (Figure 35). However, as we have argued

elsewhere (Pope and Robert et al, 2006), the Government’s original rationale

for TCs was clearly target-led and therefore to the left of the figure; the aim

was to significantly reduce waiting times as part of the drive to improve

patient care (for instance, the NHS Plan argued that the separation of elective

and emergency care afforded by TCs would allow them to ‘concentrate on

getting waiting times down’). Targets of a maximum three-month wait for an

elective admission were set and TCs were seen as a vital mechanism in

achieving these targets. Placing the macro-level management of TCs under

the umbrella of the Department of Health Waiting, Booking, Choice

programme underscored this. In contrast, while the defining characteristics of

a TC provided by the Modernisation Agency resonated with the Government’s

ambition to increase productivity and thereby reduce waiting lists, these

drivers were not quite as central for the Modernisation Agency because their

main aims were ‘modernisation’ and supporting front-line staff to think and

act differently. The Modernisation Agency’s representation of the TC concept

was shaped much more by their focus on improvement and embedded with

the stylised language and terminology of NHS modernisation (for example

‘redesign’, ‘radical’, ‘empowerment’, ‘innovative’ and ‘new ways of working’)

and therefore somewhat nearer to the notion of ‘local innovation’ as

represented by the right of the figure. How NHS TCs sought to juggle and

balance these different change pressures became an integral part of the local

management and developmental process.



Figure 35 From a ‘targets-driven’ to an ‘incentives-driven’ approach

Source: Department of Health, 2006b (The NHS in England: The operating framework for 2006/7)

Thinking about innovation and change more broadly

Recent research funded by the NCCSDO R&D programme (Greenhalgh et al,

2005; p.82) helps us to conceptualise this shift in the approach to innovation

and change in broader terms by proposing a continuum of the contrasting

traditions of what innovation is and how it spreads in service organisations,

such as health care (Figure 36). As Greenhalgh et al note (ibid; p.80), there

is a ‘vast range of research traditions whose work has a bearing on the spread

and sustainability of innovation in health service organisations’. Figure 36

seeks to represent these traditions in terms of:

a the level of intervention (from ‘let it happen’ to ‘make it happen’) that

they assume beneficial (and possible)

b the defining features of the various traditions

c the assumed mechanisms by which innovations spread according to the

traditions

d the types of metaphors used by the research traditions to describe the

spread of innovation.

In terms of representing the emerging ‘new’ Department of Health, model 1

as described at the start of Section 10.3 would sit over to the right of this

continuum among the linear and rationalist conceptual models in which an

innovation is a ‘thing’, adoption is an ‘event’ and implementation is a rational,

controllable process that is amenable to advance planning and monitoring

against targets’ (ibid; p.81). The introduction of TCs (Section 2) was

somewhere between this ‘make it happen’ and the ‘help it happen models’. To

the left of the continuum lie the models in which ‘innovation, adoption,

implementation and sustainability are complex, context-dependent and

creative social processes that cannot be planned in detail and are not

amenable to external control or manageability’. A combination of models 2



and 3 (reflecting the Department of Health’s new position that ‘change is

driven more by incentives to respond to patients…’ would sit somewhere

roughly between the ‘help it happen’ and ‘let it happen’ points on the

continuum (although nearer to the former than the latter). Viewed in this

way, the shift in the paradigm and theory of innovation and change appears

to be fundamental, leading one to question whether it is more or less likely to

offer fertile ground for service innovations to grow and flourish.

Figure 36 Different conceptual and theoretical bases for the spread of

innovation in service organisations

Source: Greenhalgh et al, 2005

Significantly, TCs in the NHS have evolved as an organisational innovation

just at the time when this shift in approaches began to take form in health

care policy-making; some of the confusion and uncertainty as related by our

case study sites and described in earlier sections in this report would seem to

reflect the inherent tensions between these different models.

Differing ‘frames’

One vital but as yet unexplored aspect of this tension between ‘make it

happen’ and ‘let it happen’ is the rather important question of what the ‘it’

actually is. We found that there were major differences between the concept

of a TC as envisaged by key actors at different levels in the NHS, across

different professional groups (including, of course, managers) and between

the groups we have called idealists, opportunists, pragmatists and sceptics

(Section 3). In examining and comparing the variety of local incarnations of

TCs with each other and with the ideas expressed across different levels and

groups as to what a TC was, we drew on ideas developed by Erving Goffman

around frame analysis (Goffman, 1974; Snow et al, 1986). We have

suggested elsewhere (Pope and Robert et al, 2006) that the innovation called

‘TCs’ was created by interconnections and interdependencies of meanings



operating at different levels in the health system, for example the macro (for

example Department of Health) policy level, mediated by a meso (for

example SHA) level (House et al, 1995) and implemented at the micro-level

at each local TC. The idea of ‘framing’ suggests that the frame or definition of

the meaning provides conceptual or cognitive structures which shape both

how TCs are viewed and, in turn, how they are enacted.

We identified three frames of particular interest to the study of TCs: the

Government frame, the modernising frame and the TC frame. The

Government framing of TCs (described in Section 2.2), provided the

definitional components; it centred on separating emergency and elective

services, delivering faster services with increased throughput, and

encouraging the use of both private sector and NHS facilities. Its rationale

was to reduce waiting times and import new ways of delivering care. The

modernising frame (described in Section 2.3) was more clearly focused than

the Government frame. It set out, for example, to list the core characteristics

of a TC (Section 1.1). Yet on closer inspection, the list was not only vague

(for example it never defined ‘high volume’ activity) but also shifted subtly

over time. This allowed our third, local frame to create and recreate different

meanings which, as is described in Section 6 (et passim), were very varied

solutions to local organisational problems.

These are just three of a potentially long list of existing or potential framings

of TCs, but they provide examples of frames that we see as having been at

once distinct and interconnected during the early phase of TC evolution.

These three frames surrounding TCs are located at different organisational

levels: the government frame expressed at the macro level of health policy

and politics, the TC frame rooted in the micro level implementation, and the

modernising frame, we suggest, mediating the other two. This latter function

was carried out by the Modernisation Agency (although regional offices, SHAs

and NHS Elect might also be said to have a variety of other meso-frames). In

this sense, ‘meso’ refers not simply to a middle layer of the organisation but

one that, for example in terms of allegiances, can be more or less allied in

various ways to the macro and micro frames. In fact the Modernisation

Agency in its earlier phases was much more closely allied to the centralised

macro level policy-making than to the local TCs’ frame.

All three frames had some common features, such as the separation of

elective and emergency care, but in fact the commonalities were remarkably

few. The macro-frame of the Department of Health had its origins (Section 2)

in the Department of Health’s responsibility to provide advice and execute

ministerial policy, and was situated within a wider context of a large-scale

political programme of health service and public sector reform directed by the

Labour Government since 1997. Thus the Department of Health macro-frame

encompassed a number of other key health service initiatives (Section 5)

such as Patient Choice and the independent sector TC programme. Within

that frame it therefore made perfectly good sense for the Department of

Health (like the Government in its own macro frame, which was related to but

not the same as the Department of Health frame) to see the TCs as part of

that package of initiatives. In contrast, the micro-level frame of the local TCs

encompassed a quite different set of concepts and activities, shaped by the

milieus and the motivators described in Sections 3 and 4, such as

redevelopment of local day surgery, competitive advantage, income



generation, or an alteration of patient-booking methods. From within this

frame the plethora of initiatives that represented the macro frame made very

little rational sense; it was just a flurry of ‘must-do’s’ with little or none of the

consistency that was apparent to the politician and civil servant originators of

those policies. The Modernisation Agency’s meso-frame, while sharing some

of the aspects of both macro and micro (for example Patient Choice, new

booking practices) – also differed from them by having less of an emphasis on

other aspects (for example private provision or on local income generation).

Rather, it focused on streamlining services, improving the patient pathways

and re-engineering professional roles, and on sharing and disseminating best

practice (see Section 2.3.1). Thus each frame had its own (often implicit)

definition, rationale, and image/identity, terminology and above all its own

interpretation of the meanings of phenomena associated with TCs. And each

frame had its own concatenation of associated values, concepts, policies and

activities. The crucial point about frames is that they at once define and are

defined by all these phenomena. And of course the same applied not only to

the three frames that we have exemplified here, but also to other frames

such as the SHAs and regions (Section 4), and to groups such as managers

and doctors (Sections 3 to 6), or idealists and sceptics (see Section 3.4).

We found that the differences between the frames had major consequences

for the interactions between the key players, which informed many of the

variations that resulted in both the reality and perception of the innovation

(Sections 6 and 7). Contests of meaning were a crucial part of the evolution

of the TCs as described particularly in Section 6, whose formulation – or

‘innovation journey’ (Section 10.2). – was the result of these conflicting

interests and forces (described in Sections 2, 3 and 5) pulling in differing

directions. And that result, of course, was dependent not only on the direction

of those forces but on the political and organisational weight that their

protagonists could bring to bear. This, moreover, is closely related to the

general policy environment discussed above, namely whether the power lies

mainly at the centre or with local innovators. And this of course means in turn

that the proposed replacement of a top-down approach with local incentive

frames will have an important bearing on innovation journeys; (as well as

inevitably being very differently perceived within different frames!). We

therefore return to the implications of that general shift in the policy

environment, but now with the added insight that when central and local

players tussle over an innovation, making, letting or perhaps preventing ‘it’

from happening, they each perceive a different ‘it’ from within their various

frames.

10.3.2 Likely implications for service innovation and

improvement

The vision upon which the shift from ‘top-down target-led’ to ‘local innovation

and incentive-led’ is based was initially set out in Health Reform in England:

update and next steps, written by the new Department of Health Policy and

Strategy Directorate and published in December 2005, and it is to this that

we need to turn for the details, all of the time considering the possible

implications for TCs and future organisational innovations, and what we know

from previous research as well as what we have learnt from our own study.



The document in question outlines a new model for policy development over

the next three years, orientated towards the final phase of the Government’s

10 year modernisation plan. Its whole tone is about abandoning the top-down

approach (model 1) and recognising that while the centre cannot direct or

manage innovation and change, it can and should be seeking to enable,

motivate and regulate it (in the words of this study, create a receptive

external milieu or context). In line with this, Ferlie et al (2006; p.67) point

out that ‘academically, the role of strong incentives in interacting with and

reshaping organisational tracks has not been considered fully in prior change

management work in health care… perhaps because previous incentive

structures have been relatively weak’. They also suggest that ‘the role of

incentives is neglected in the change management literature which is more

sociological in character and assumes that incentives will be too weak to

change embedded behaviour’ They go on to suggest that an organisational

economics perspective may have greater value in the future.

The Government’s aim – as outlined in Health Reform in England – is to

create a ‘self-improving,’ ‘self managing’ NHS, and significantly for TCs and

other innovations, ‘to achieve an in-built dynamic for innovation and

improvement’ (p.10), and ‘providers with more freedom to innovate and

improve services’ (p.6). Other relevant phrases include ‘greater local

involvement and self determination’ (p.9), ‘empowering people locally’ (p. 9),

‘a self-improving NHS led by patients and the public in partnership with staff’,

‘rule based to incentive based… new incentives to enable health care

professionals and NHS managers to better respond to the needs and

preferences of their patients’ (p.7), and ‘flexibilities within a context of

system rules’ (p.8). Most of these are covered by the so-called ‘supply side

reforms’ indicated by the right hand box of the Department of Health’s new

model below (Figure 37) and its accompanying annex (see Appendix 7) which

appeared in the same document. All of this seems aimed at giving providers

and innovators and change agents such as our eight case study trusts and

front-line professionals and local managers such as the TC staff within them

‘the incentive to improve services in response to the needs of their patients

and local populations’ (p.20).

So what are the likely implications and prospects of these recent policy and

governance developments both for the future of TCs and for service

innovation and improvement more generally within the NHS? What will the

words mean in practice, if anything, and will they make a difference in terms

of the ‘doing’ of organisational innovation and change? If our TCs had been

introduced into this kind of context might they have evolved in different ways

and might they have had any greater or lesser impact, and chance of survival

or expansion? Will the context or milieu become more or less ‘receptive’ as a

result of this change of policy context? How might the new profile alter the

dynamics of innovation and improvement as they get played out in the many

ways we have described, or indeed alter the manner and direction in which

innovations like TCs develop, and their resulting impact on quality, efficiency

and effectiveness of care? None of these questions is hypothetical. This is the

policy context in which our surviving seven TCs now find themselves, and in

which any new or current TCs, public or private, will have to operate; the

implications for practitioners that arise from this changing policy context are

discussed below (see Section 10.4).



Figure 37 Framework for the reforms

Source: Department of Health. 2005. Health reform in England: update and next steps

The first thing to note (a recurrent theme in this report) is that there always

was considerable variation between TCs locally, and between what central

Government (the Department of Health and the Modernisation Agency)

wanted/expected and what the TCs locally were prepared to give them see

Pope and Robert et al, 2006, for a further discussion). This is despite the

existence of ‘Big Brother’ model 1, which suggests to us that, if the TCs are

anything to go by, the Department of Health was wise (and perhaps had little

choice but) to abandon a model which had clearly already lost much of its

directive power! De facto, and some would say perversely, our TCs therefore

displayed many, if not most, of the features of the new ‘local innovation’

model even before it was introduced, a case perhaps of policy following (and

legitimising) practice rather than leading it. For instance, Ferlie et al (2006,

p.71) – in their study of seven health care providers engaged with London

Choice – found that ‘some of the diagnosis and treatment centre capacity was

pre-existing and relabelled for choice’. This finding was corroborated in a

number of our case study sites.

It still needs to be asked, however, (not least for fundamental reasons of

governance) how did a clearly prescribed policy initiative give rise to such

diversity of product and outcome? TCs were given a clear policy objective

(that is, the reduction of waiting times), a set of principles related to their

development (the Modernisation Agency’s desiderata) and a timeline to do it

in. Yet they all evolved differently from vision to product, (some rapidly, some

more slowly, some never), clearly constructed to suit local needs and agendas

rather than any national blueprint, and striving to stand out from each other

as much as to conform – an innovation terrain thus marked by colour and

diversity rather than any discernable policy monochrome.



Is this really any surprise, however? Pressman and Wildavsky’s (1973) classic

study of policy implementation explored the efforts of the US Federal

government’s Economic Development Administration (EDA) to create jobs for

the long-term unemployed in Oakland. The research showed how the EDA’s

attempts to implement policy in Oakland suffered setbacks that were not only

costly but typical of the problems encountered in federal-local projects. The

authors suggested four possible reasons for central objectives not being

realised. One explanation is the assertion of faulty implementation. Another

explanation may be that aspirations were set too high. Thirdly, the possibility

of a mismatch between means and ends calls into question the adequacy of

the original policy design (perhaps implementation was good but the theory

on which it was based was bad). Finally, could a different set of initial

conditions have achieved the predicted results? Warren (1974) further

suggests that the most important maxim to be learned from their tale of

programme failure is that ‘implementation should not be divorced from

policy’:

In other words, programs fail too frequently because too much respect, effort

and enthusiasm are given to program design, obtaining initial support from the

participating community and funding, while the implementation stage is

regarded as the easy part involving only routine, technical questions that can

always be worked out later as long as the program itself is sound …

Commenting on the Oakland failure, they [Pressman and Wildavsky] assert

‘…these seemingly routine questions of implementation were the rocks on which

the program eventually floundered’.

(Warren, 1974; p.1090)

While not all our case TCs could be described as having ‘floundered’ to quite

the same extent as the EDA programme (though some quite clearly could),

the above characterisation of the discrete attention typically paid to the

‘policy’ and the ‘implementation’ phases (see following ‘implications for

practice’ section) of organisational innovations in the public sector resonates

strongly with our own findings. Clearly there was a hiatus between top level

policy guidance and advice in terms of TC form and process, which was not

helped by the dissolution of the Modernisation Agency and its TC team

midstream, and the reorganisation of SHAs, both of which tended to remove

whatever weak ‘meso’ connectors already existed. The innovation literature

has spent a lot of time looking at the issue of co-ordination and autonomy,

but not this — in our view equally important — issue of connection. In our

opinion this merits more attention than it has attracted to date particularly in

multi-level organisations like the NHS where such connectors are the only

means through which it operates as an ‘innovation system’ rather than

collection of fragments.

Brooks and Bate’s (1994) analysis of a change programme in the British civil

service in the late 1980s/early 1990s found a similar picture of

underachievement where the local context acted against top-down attempts

to introduce transformational change. In their proposed matrix of possible

scenarios for a change programme they suggested that the British civil

service was unlikely to move towards transformation (planned or unplanned,)

but that it would either stay the same or take on less radical elements of the

change programme. More recently – and more immediately relevant to the

NHS context – Exworthy et al’s (2002) study of the adoption of policies to

address health inequalities in the UK again bears remarkable similarity to the



findings of our research into TCs. They found that although national

policymakers viewed policies to reduce health inequalities as an innovation

developed and supported centrally (and intended to be disseminated

vertically for adoption at the local level), and although there was strong

alignment in the values underpinning both central and local policymaking on

inequalities, there was little or no direct vertical cascading of this policy. In

reality, what central Government saw as uptake of the ‘innovation’ (policies to

reduce inequalities) was actually a rebranding of existing initiatives to fit the

new category (and new budget) assigned to ‘inequalities initiatives’). [Note

that this commentary on Exworthy et al is drawn from that of Greenhalgh et

al (2005; pp.173-174), two of whose authors were also authors of this

report.] Such disconnections between central policy and implementation as

revealed by Exworthy’s – and now our – research raise big questions as to

what the role of central Government is and should be, given that at least in

the area of innovation it appears not only to have lost its directive power but

seems to have relatively weak influence upon what happens locally. The

implication for central policy must be that it needs to concentrate on framing

implementation (setting boundaries and common rules and frameworks)

rather than trying to directly determine it.

That being said we cannot simply dismiss national policy as always irrelevant

or of no help or consequence – as indeed the TC programme showed if only

by giving impetus, headroom and resources to new initiatives on the ground .

The systematic review of the diffusion of innovations in health service

organisations by Greenhalgh et al (2005; p.14), although not intended to

focus on the policy making/implementation literature, reported on several

empirical studies which measured the effect of the policy context on the

adoption of a particular innovation. The review found that:

A policy ‘push’ occurring at the early stage of implementation of an innovation

initiative can increase its chances of success, perhaps most crucially by making

a dedicated funding stream available. External mandates (political ‘must-dos’)

increase the predisposition, but not the capacity, of an organisation to adopt an

innovation; such mandates (or the fear of them) may divert activity away from

innovations as organisations seek to second-guess what they will be required to

do next rather than focus on locally generated ideas and priorities.

This describes what we found with the TCs: it will be recalled that not only

significant amounts of capital funding for new buildings and the renovation of

existing facilities, but also other significant ‘slack’ resources were made

available by central Government to those seeking to implement a TC locally.

The latter included, for example, the Modernisation Agency programme, NHS

Elect (see Section 5) and more recently funding for the AmbiCentres

International initiative. [Note that AmbiCentres was formed in 2004 to ‘carry

forward our faith in the provision of health care through treatment centres’

and its website contains a database of TCs, a library to support best practice

and a forum for anyone interested in TCs. As such it has a key role to play as

one of the few remaining ‘connectors’ in the TC process (see

www.ambicentres.net).]

Thus it could be argued that the direction and support from central

Government for the TC programme did in fact do quite a lot to ‘help it

happen’, had it not been that so many other initiatives made it almost

impossible for it to happen as anyone had originally envisaged. Moreover it

could also be argued that in such circumstances, it was inevitable that local



solutions would need to be found that moved towards the initial ideal of a TC

while also trying to optimise movement towards many other ideals that were

sometimes not only pulling in different – indeed contrary – directions, but

creating elephant traps.

Taking the new policy context at face value we can view TCs and future

service innovations in the context of what we perceive from the key

documents (Department of Health, 2005f; 2006b) to be five main conceptual

components that make up its core. We see these five as being a rules-based

system, incentives, freedoms, performance and patient involvement and

patient-centred services. Any or all of these components, we suggest, might

shape the nature of these innovations and the direction they may take in the

future. As there remain so many unknowns we have chosen to illustrate the

range of potential issues raised by this ‘new’ policy context by focusing on the

first two of these five components. Much of the following is in the form of

questions for further consideration by policymakers and researchers.

a) Rules-based system

The first component of the new policy stresses the move to a rules based

system, recognising that any national policy guidance ‘can only set the

parameters within which local organisations will work’ (Department of Health,

2006b; p.3). Perhaps a new and more constructive way of conceiving such

system rules – and a useful way of moving away from the traditional

‘rule=obligation’ or directive mindset – might be in the form of ‘design rules’

for innovation’ (Bate and Robert, 2007; Bevan et al, 2007; Plsek et al, 2007).

These would consist of the imperatives and ‘must do’s’ distilled from

experience and practice which enable one to say: ‘If you want to achieve

outcome (for example, encouraging local innovation) Y in situation S,

something like X might help’. Viewed as design rules rather than behavioural

rules the emphasis moves from a mindset of control (which many perceive in

negative terms) to knowledge, positive learning and evidence about what has

worked, and more importantly why and how it has worked in the way that it

has.

This idea of positive – ‘glass is half full’ – mindset has created a whole new

area of research and practice known as ‘positive organisational scholarship’,

which its advocates argue is a transformative mindset especially for

bureaucracies and bureaucrats such as the NHS. Certainly, a positive

organisational scholarship approach to TC innovation would have been very

different from the one that we observed, with far greater emphasis upon

possibility and the abundance of opportunity and far less on scarcity, negative

politics and constraint (see Cameron et al, 2003). Such an approach pushes

all interested stakeholders to ask:

• Are there design principles for implementing organisational innovations

in health care, including TCs? If so what are they?

• What are the key considerations to be borne in mind?

• What are the tried and tested design exemplars (for something like a TC)

that we already know about?

Answers to such questions are most likely to come from those who have close

experience of managing the innovation in question. Part of the work of the

Modernisation Agency during the duration of our study could be represented



as working with such managers to seek out the answers to questions about

‘what’ design principles had worked. However, in the case of TCs, they were

not able to get to the heart of ‘why’ and ‘how’ those principles succeeded or

not. Thus at the learning events, for example, where it might have been

possible to reflect on the details of how and why some design rules worked or

not, and to develop them collectively, there was reluctance to do so. The

events were carefully stage-managed and if there was a sharing of the deeper

concerns and why and how of developing TCs, it happened mainly in the

informal networking, and not as part of the explicit sharing of practice.

Perhaps in a performance-driven, competitive NHS, the Modernisation Agency

and the TC managers were careful not to delve too deeply in their ‘learning

events’ for fear of disturbing the illusion of a shining innovation and bringing

shame upon one’s own house. Instead, the public processes seemed to us to

collude in ‘keeping up appearances’ rather than genuinely striving to develop

realistic design rules. Yet at other (non-Modernisation Agency) fora, we heard

chief executives and senior clinical managers delivering polemics about the

adversity of the environment and its effect on the TC – to the extent of

showing graphics depicting ‘the perfect storm’ to describe the totally adverse

policy context that they felt was overwhelming the TC initiative.

If neither the Department of Health nor the Modernisation Agency were – for

whatever reason – unable to foster the collective development of design rules

during the period of our study, then who in the new-look NHS will be

responsible for creating and implementing the new rules? The Department of

Health is in no doubt:

There will be a great responsibility on new strategic health authorities (SHAs) to

ensure than guidance is implemented locally, that the new system and

organisations [PCTs and\ Foundation trusts] are developed rapidly and

effectively, and that problems are successfully managed locally.

(Department of Health, 2006b; p.3)

Apart from observing that the tone of the above clearly remains compliance

rather than commitment based, we also need to ask – challenge – whether a

future SHA driven, rules-based system that holds organisations accountable

for what they do should be any different from what has preceded it. For

example we have seen how marginal the SHAs and PCTs have often been in

TC development (due in part to the central commissioning process that

characterised the early implementation stages of both NHS and independent

sector TCs). One other reason, revealed in our interviews with external

stakeholders, was that these organisations were themselves at an early stage

of their development and they were unclear and uncertain about what their

role should and could be, and what it could realistically deliver. On current

evidence, these questions have not gone away, and it remains to be seen

whether SHAs will ever be able to accomplish such a sea change.

To put these real life issues in a conceptual context, recent literature makes

the point that innovation processes and outcomes depend upon how an

organisation deals with the ‘coordination-autonomy’ dilemma (Puranam et al,

2006). That is to say, how might the NHS deal with the competing pulls

between the need for coordination mechanisms such as standard operating

procedures, routines, and shared language that enable mutual learning and

‘system gains,’ and the need for autonomy and the incentives this gives

people to take the necessary initiatives to innovate and try new things.



Clearly the new policy and governance arrangements are seeking, as always,

to deal with the necessary balances and trade-offs between them but it is too

early to say how this will ultimately resolve itself. Arguably in the past, and

despite the powerful unitary intentions of the centre, there may have been

rather too much autonomy beneath the regional/SHA level, leading to

fragmentation and loss of some of the gains that might have been made as

the result of the stakeholders in the local health economies working more

closely together on specific issues such as TC development. This may seem

surprising to some observers who claim that the Department of Health has

been too ‘hands on’. But our observations of the development of TCs suggests

that, paradoxically, it was the very plethora of central directives (and the lack

of a core of common design rules) that made it essential (and possible) for

each locality to steer its own apparently autonomous course – the course that

seemed to local managers most likely to optimise the achievement of their

particular confluence of conflicting demands.

A design-rules-based approach such as we have described might give clarity

on both sides: clarity for the SHA in framing design rules which, being broad

and confined to the ‘what’, take nothing away from local autonomy in

deciding the detail and the ‘how’ but at the same time establishing clear

parameters for accountability, but also organisation design. But it would also

bring welcome clarity for TCs, if it could avoid too great an emphasis upon

benchmarking and prescriptive detail (which in the case of the TCs often got a

negative reaction) and also reconcile the twin pulls of advice, guidelines and

support on the one hand, and targets and performance management on the

other, which the Modernisation Agency, as with so many other Modernisation

Agency programmes at the time, never really managed to do.

b) Incentives

The modern idea of an incentives-driven rather than targets-driven NHS

raises an interesting question about what, if any, difference this might have

made to the way TCs have developed in the past and how they will develop in

future. So, what are the mechanisms for those incentives in the specific

national policies that have been introduced to encourage – notionally at least

– the development and operation of TCs and other forms of local innovation

and service improvement? We find three main mechanisms: practice-based

commissioning, Payment by Results and Patient Choice.

Practice-based commissioning: The aim of practice-based commissioning

is to give primary care practices the freedom, support and incentives they

need to improve care and services for their patients, within a governance

framework that ensures value for money and fairness, the priority being to

achieve universal coverage by December 2006. We saw in a number of our

case study sites a recognition of the importance of marketing TCs much more

effectively (and directly) to GPs, although the building of strong transactional

relationships had not really begun in most cases. Whether the necessary skills

and resources for such marketing will be found is open to some question,

although a number of our TCs had begun to establish a marketing function

within the TC or wider trust.

Payment by Results: The Payment by Results system aims to reward

quality and efficiency of both commissioning and providing, and will involve

planning, coding, costing and scheduling systems, and performance data and



monitoring that are far more rigorous and transparent than many of our TCs

seemed willing to provide, or capable of providing, at the time of our study.

Therefore, not only is this likely to represent a push towards the greater

professionalisation of TCs, it may also help to create closer and more mature

relationships between commissioners and providers, which again were

missing in a number of our TCs. On the other hand, some TC managers

believed the way that the calculations on costs are done (that is, based on

aggregated and averaged figures) would unfairly favour some sites over

others, and therefore contribute to their sense of an ‘unlevel playing field’.

Patient Choice: The Department of Health’s intention is that giving patients

more options and increasing competition between providers will act as an

incentive for providers (including TCs) to innovate and achieve higher levels

of performance in terms of quality, service efficiency and activity levels (Bate

and Robert, 2005; Ferlie et al, 2006). Of course, patients did already have

some choice of TC during the period of our study (see Section 5), which for a

whole range of reasons – discussed in passing here and in more detail

elsewhere (Bate and Robert, 2006; Exworthy and Peckham, 2006) – many

patients chose not to exercise. This in itself raises some doubt as to how far

choice will act as an effective incentive mechanism in the context of TC

development in future, particularly new ones where there is no previous

patient association, affiliation or history of attendance. However, 2006/7 will

be very different from the previous three years, and a big step forward is the

extension of Patient Choice from the currently prescribed minimum of four

hospitals to also include any NHS foundation trust and, significantly for this

study, ‘any nationally procured independent sector treatment centre, and any

other subsequently centrally accredited independent-sector providers’

(Department of Health, 2006b: 9). Waves 1 and 2 of the independent sector

TC programme were expected to deliver more capacity and choice for NHS

patients, and all of the wave 1 centres were expected to be operational by

2008, delivering two million diagnostic procedures and approximately

250,000 episodes. The programme was expected to include elective surgery,

and ophthalmic, orthopaedic and general surgery, in addition to significant

levels of diagnostic testing. However, the recent decision to cancel seven of

the 24 planned local independent sector TCs (£550m of work per annum)

because ‘the Department of Health was forced to acknowledge claims by

SHAs and PCTs that more elective capacity was not needed in their regions’

(Health Services Journal, 2006) reflects many of the earlier doubts expressed

to us in our research about the desirability of such a rapid expansion of

elective capacity in some areas of the country. The remaining 17 schemes

have been delayed for up to a year. Ferlie et al (2006; p63) point out that

‘choice necessarily implies the existence of surplus capacity so consumers can

‘shop around’ and ask whether ‘health care providers [can] speedily produce

the substantial additional capacity needed’ Our findings would suggest that

yes, they could and in fact that expansion in capacity (in both the public and

private sectors) has in fact run some way ahead of the implementation of the

Patient Choice agenda itself; leading, in part, to the decision to cut back on

expansion in the private sector in some geographical areas in England.

This also takes us back to assertions made by several people that we

interviewed in our TCs that the competition with the independent sector was

not being held on a level playing field. If this indeed turns out to be the case

(as it sometimes – see Section 6 – already has), then it may doom many



NHS-run TCs in the longer term, especially those currently suffering from a

patient famine. Clearly, an incentive will only be an incentive if those involved

perceive some chance of winning or even equalising during the ‘game,’ and

some balance between the sides in terms of numbers, resources and rules –

which is not how many have seen the situation to date (another barrier to

positive organisational practice). A related point is around the question of the

‘diagnosis’ part of the original diagnosis and treatment centres. We have seen

how the ‘D’ disappeared quite early on from the NHS-run TCs (in some cases

just a name change, in others a real shift away from diagnostic work or a

narrowing of ambition). However, the wider independent sector TC

programme will clearly be providing high volumes of diagnostic work in the

future, in so doing reintroducing an aspect of this innovation that had been in

danger of being lost (and remains so at least from the majority of NHS-run

TCs; again this may have implications for their ability to compete with

independent sector TCs in the future).

From a policy point of view it is therefore worth questioning whether, in the

present context, competition between TCs in the NHS and the independent

sector will provide the ‘in-built dynamic for innovation and improvement’ and

the ‘self-improving NHS’ that the Department of Health is looking for, or

whether policy – if it genuinely wishes to promote NHS-run TCs – needs to

support a fairer ‘game’. But even if the playing field were level, as we will see

in the next section, Patient Choice has potentially profound implications for

the way in which a TC might operate – implications that have so far been

ignored by policymakers.

10.3.3 Research and policymaking in the NHS: modelling

and the conflict of policies

The following section is grounded in the results presented by the quantitative

modelling reported in Sections 8 and 9. In the discussion, one key theme

emerges, albeit in different guises, from both the qualitative and quantitative

strands of the research – the problem presented to organisations by

unpredictable variability. Another theme is the need for a ‘whole-system’

approach in evaluating this innovation in the delivery of health care services.

Having illustrated how some of the components of the new Department of

Health policy context seem likely to impact upon organisational innovations in

the NHS in the coming years, we now conclude our discussion on the

implications for policymaking on the future of TCs by briefly discussing the

extent to which it is possible to influence policy implementation through early

evaluation. This section draws on work by two of the authors of this report

(Gallivan and Utley) with regard to the planning of the early pilots of Patient

Choice and the likely implications of this policy for the NHS TCs as predicted

in 2002. It is worth noting that these debates are part of a wider discussion

about the very notion of implementing ‘evidence-based’ policy making (see

for example Black, 2001; Sanderson, 2002; Bate and Robert, 2002; Bate and

Robert, 2003; Saetren, 2005; Learmonth and Harding, 2006).



Predicting clashes of policy: evaluation of policy prior to

implementation

In Section 6 we described how two of our study sites had expected to treat

many more patients under Patient Choice than they eventually did. The

problems encountered by these TCs were predictable. Indeed in 2002, as part

of an exercise carried out in preparation for a pilot of Patient Choice, Gallivan

and Utley (2002b) made two key observations:

1 A system in which patients are guaranteed a choice concerning where

they are treated inherently requires more capacity to be available than is

actually used.

2 By requiring participating centres (including the two study TC sites) to

commit to reserve certain levels of capacity but only reimbursing them

for the number of patients treated, the pilot of Patient Choice was

transferring a degree of risk onto the participating centres.

It should be noted that these observations were made prior to the

implementation of the Patient Choice pilot and before any empirical evidence

was available. Instead, they were based on a process of thought experiment,

guided by the experience of how complex systems tend to behave.

Quoting directly from Gallivan and Utley (2002b) discussing the feature of the

pilot of Patient Choice whereby participating centres made a commitment to

provide a certain level of capacity:

However, there might be circumstances where this is likely to be prohibitively

expensive if [participating centres] are remunerated for capacity reserved rather

than patients treated. If, on the other hand, remuneration is made purely on the

basis of patients treated, managers at [participating centres] may well be

reluctant to reserve the requested amount of capacity, as the majority of it is

likely to go unused.

In the event, it seems that managers at the TCs affected were, perhaps

unsurprisingly, unaware of the risk to which they were being exposed. A

parallel can be drawn between this feature of the pilot of Patient Choice and a

potential clash between the policy of Patient Choice (which has an intrinsic

requirement for more capacity to be available within the system than is

actually used (Gallivan and Utley, 2002b; 2004) and Payment by Results

(that reimburses providers on the basis of activity).

In addition to further illuminating the challenging environment in which our

sites were operating, the fact that such difficulties had been predicted prior to

the event raises an interesting question concerning the role of mathematical

modelling and operational research with respect to health service operation.

We discuss below how no amount of rational planning, however sophisticated,

can fully equip those charged with implementing change and innovation in an

organisation as complex and unpredictable as the NHS. While the use of

mathematical models of the type discussed in Section 8 could help managers

to take account of some aspects of unpredictable variability in their planning,

there are intrinsic limits to the extent to which such models can reflect all the

complexities of real life, and what will work. However, mathematical models

can be extremely useful in predicting what will not work and identifying

hidden pitfalls. This is particularly the case prior to a policy being

implemented when evaluation cannot be based on standard methods of data

collection and analysis.



It is interesting to draw a comparison between health care and transport

planning, another area concerned with providing a large scale and complex

public service. Before the introduction of any major change in a transport

system, huge amounts of high quality mathematical modelling and

operational research and planning is carried out. Major research centres, such

as the Transport Research Laboratory have been established, employing

hundreds of scientists whose work focuses on the topic of transport and there

are many more working in local authorities and the private sector.

This is in contrast with health. Certainly there is massive research funding for

biomedical research, but when it comes to evaluating health policy changes,

there are relatively few centres with the capability for carrying out relevant

mathematical modelling. Even when it is applied and highlights potential

problem areas, the results seem unwelcome. One piece of work (Gallivan and

Utley, 2002a) carried out for Patient Choice indicated many difficulties that

might arise, many of which came to pass (for example the potential

promotion of cartel arrangements, the provision of incentives to defer

treatment, quality migration, the ‘uneconomics’ of scale, chaotic queue

behaviour, the potential restriction of access, the funding of activity rather

than capacity, the consequences of increased patient travel and human

resource implications). A follow up study (Gallivan and Utley, 2002b)

reinforced the view that there was potential for a large amount of capacity to

go unused. The reaction of the organisers to the latter work was to stop

responding to communications and the invoice for the work remains unpaid.

From the outside, this seemed consistent with an organisation in a state of

denial.

Although such work can have a very positive role in promoting effective policy

and avoiding pitfalls, it is recognised that the activity involved is essentially

‘devil's advocacy’. Such dispassionate critical review of proposed policy

changes can be an emotionally challenging process for an organisation to

submit itself to, particularly if it has already fully convinced itself of the

merits of an idea. It is recommended that new policy ideas should be subject

to independent, dispassionate devil's advocacy exercises. The availability

within the UK of groups with the relevant experience to undertake such

analysis is at present limited. This is not a role well-suited to consulting firms,

since there would be a potential reluctance to make recommendations that

are likely to be very unpopular with the client.

It is our view that this is an area where operational research has a significant

role to play but is underused within the UK health service. One of the key

roles of such analysis is to discard options that show unforeseen and

detrimental effects on estimated system performance. The ethos in much of

this work is that ‘while an idea that works in theory may not work in practice,

an idea that doesn't work in theory has very little chance of working in

practice’. The detrimental policy clash between the TC and Patient Choice

programmes, so easily predictable in 2002, and so clearly manifest in our

fieldwork, is stark evidence for this.

10.4 Conceptual implications of the research

Much of the thinking around organisational innovation will essentially be the

same as the broader business of managing change, and therefore the same



rules, models and theories of change might be expected to apply (see review

in Iles and Sutherland, 2001). We will therefore not reiterate them here, but

focus instead on two of the major areas where important findings that

emerged from our study of TCs: the ways that local managers (1) plan and

(2) make decisions in such a turbulent environment.

Few would wish to challenge the contention that better, more rigorous, more

intelligent, more systematic planning over a less compressed time period,

with more stakeholder engagement and relationship building would indeed

have reduced the gap between plan and reality, and hence averted many of

the TCs’ ensuing problems. However, it still leaves a question as to how far

the TCs could have accurately predicted, and subsequently managed, for

example, their workload and activity levels, when their external milieu was

subject to so many unanticipated changes. ‘More and better planning’ is

therefore only part of the solution; the other part is how those involved can

get better at managing innovation and change in conditions of high

uncertainty and growing volatility and complexity.

10.4.1 Planning and complexity

One key point for future NHS innovation is that we cannot simply view and

adjudge the management of innovations like TCs from within the safe

confines of the mainstream ‘planning’ paradigm. We need instead to raise

questions about the paradigm itself – or at least to be aware that whatever

conclusions we draw will be shaped by this. For example, Fonseca writes:

Regardless of whether innovation is thought of as a ‘hard’ scientific and

technological process, a rational management process, or a ‘soft’ intuitive

human process, all these perspectives have in common the assumption that

innovation is a phenomenon that can be subjected to human control. It is taken

for granted that humans can purposefully design, in advance, the conditions

under which change will occur.

(Fonseca, 2002; p.3)

Even assuming the plan could have been more accurate, the question remains

as to whether this would have made the whole innovation process any more

controllable. Fonseca at least would say not:

I will argue that these processes… are fundamentally uncertain, making it

impossible to design in advance the settings that will produce innovations.

(ibid; p.9)

The TCs and those in a position to assist them could clearly have done more

and better local and strategic planning than they did, as evidenced by the

decision to cancel seven of the planned 24 independent sector TCs (Health

Services Journal, 2006). However it still needs to be recognised that there are

limits to the extent to which change and innovation can be planned, or at

least planned in detail and with a reasonable degree of accuracy. It is

interesting in itself that seven of our eight case study sites ‘got the numbers

wrong’, sometimes very wrong (and even the eighth is now having serious

difficulties in agreeing the size of its planned new-build phase two TC). Better

marketing and business analysis undoubtedly would have made a difference,

and those involved did acknowledge this, but the issues do seem to run

deeper than it being a simple case of bad management and poor planning.

Perhaps this is in the nature of complex processes, where no amount of



planning and data gathering could have accurately predicted the numbers.

Like the weather, top-down planning approaches always carry the possibility

that the reality will not live up to the forecast. And to continue the weather

forecast metaphor, Quinn (1980) notes that ‘a good deal of corporate

planning is like a ritual rain dance. It has no effect on the weather that

follows, but those who engage in it think it does... Moreover, much of the

advice related to corporate planning is directed at improving the dancing, not

the weather’. As Beckhard (1997; pp.143-144) put it:

I have learned through experience and the experiences of those I have

consulted and taught that the correlation between a good plan and a good

outcome is, to say the least, unreliable. This helped me to understand … why

so many organisations’ strategic plans don’t end up in effective actions.

Beckhard’s point relating to the limits of planned change – fundamental in our

view – is that ‘getting the numbers wrong’ is not about bad planning or

sloppy thinking (although as our TCs show it can at least partly be) but about

the complex, unpredictable nature of innovation and change processes

themselves, that cannot be ignored in the hope that they become simpler and

more predictable. Instead the unpredictability must be proactively managed –

the notion of the management of innovation as the management of

uncertainty. (This was indeed recognised by many of the TC managers as

they strove to allow their TCs to evolve and survive in the changing

environment.) Kanter et al (1992; p.373) in similar vein wrote:

While the literature often portrays an organisation’s quest for change like a

brisk march along a well-marked path, those in the middle of change are more

likely to describe their journey as a laborious crawl towards an elusive,

flickering goal, with many wrong turns and missed opportunities along the way.

Only rarely does an organisation know exactly where it’s going, or how it

should get there.

Kanter (1983; 1989) also analysed hundreds of case studies and failed to find

any evidence for the success of rational planning models in most of them.

Greenhalgh et al (2005; p.80) cite this work as ‘some of the best empirical

evidence on how innovation arises in complex system’ Kanter et al (1992)

emphasise external causes such as those already noted in our cases: the lack

of data support from the wider NHS, but especially the politics of TCs trying

to manage upwards by ‘fudging’ activity forecasts to make them sufficiently

acceptable to the SHA that they would sign off the business case.

Those external, uncontrollable, and powerful forces are not to be

underestimated, and they are one reason why some researchers have

questioned the manageability of change at all.

(ibid; p.374).

External forces played their part in the TC planning debacle, but internal

managers must also bear some of the responsibility for the gross inflation of

activity forecasts we encountered in virtually all our case study sites. Those

making the case for TCs had to satisfy a tense web of internal and external

forces pulling them in various directions: the interests and concerns of key

players in both the internal and external milieus (Section 3), the often

mutually contradictory motivating forces from both central Government

(Section 2) and the host trust/TC (Section 4) and of course the subsequent

policy shifts (Section 5). This draws our attention to another neglected aspect

of research and practice: the politics of innovation. Clearly, the story of TCs is



not just about planning or the lack of it, but about politics and complex

processes of dispute, negotiation and contestation.

Taking these factors into account Table 8 summarises these two contrasting

perspectives on the management of innovation: the mainstream planning

paradigm and the complex systems view.

The complex systems view of the planning and decision-making processes for

TCs is a long way from the traditional rational model with its roots in the

classical economic theory of the firm, and a broad set of assumptions that

goals, alternatives, risk, order of preference, and data are generally known

and clear. It is also quite distant from the bounded rationality model which

assumes decision makers have limitations that constrain rationality and

therefore may not consider all possible alternatives, settling instead for a

satisfactory not optimal solution. ‘An example is the difference between

searching a haystack to find the sharpest needle in it and searching the

haystack to find a needle sharp enough to sew with’ (March and Simon, 1958;

p.141). Like Lindblom’s description of what he calls ‘the science of muddling

through’ (Lindblom, 1959), in which decision makers make do with solutions

that are sufficiently satisfactory (that is, that ‘satisfice’), bounded rationality

allows for more open and dynamic planning, with decision makers changing

direction as new information and intelligence flow in. Clearly the TCs

displayed some elements of all of these models, especially the latter two. But

what we found, sometimes in precarious and uncertain situations of political

tensions and conflicting interests, had more the feel of the ‘garbage-can

model’ applied to change and innovation, (Cohen et al, 1972; see Figure 38).



Table 8 Two contrasting perspectives on managing organisational innovation

Planning Complex systems

Assumptions rational, ordered, controllable, predictable, linear and sequential, and therefore manageable

disordered and messy, unforeseeable, unplannable, uncontrollable, flexible and emergent, and therefore barely manageable

Approach programmatic, rule-centred; building robust project management systems

pragmatic, human-centred, building ‘supportive social arrangements’ (Kanter, 1988)

Key focus structure, system and rules process and affiliation

Effectiveness better planning

tighter control and accountability

better preparation

intense network interaction, communication and relationship building

Key skills project management and organisational

political and networking

Sees itself professional and well-organised

entrepreneurial and opportunistic

Sees the other sloppy dogmatic

10.4.2 Sense-making and decision making

Pulling these various threads together, we – like others commenting more

broadly on New Labour’s approach to policymaking in the NHS (see for

example Greener, 2004b, who refers to a garbage can model which draws

freely on old ideas, giving them a new twist in a bid to secure successful

delivery) – began to see the story of TCs as more and more about sense-

making, decision-making, change-making and innovation in situations of high

uncertainty, ambiguity and volatility, where detailed planning-based models

of organisational change can be unnecessarily burdensome, unreliable or

plain useless. Explicitly recognising the tendency of intended strategies to

lead to unintended consequences, Balogun and Johnson (2005), studied the

social processes of interaction between middle managers (the equivalent of

many of our TC managers) as change recipients as they try to make sense of

a change intervention. In common with much contemporary organisational

change theory, they found that ‘managing change is less about directing and

controlling and more about facilitating recipient sense-making processes’

(p.1596).

Interestingly, the story of modern TCs is strongly reminiscent of the

‘irrational’ (Brunsson, 1982; Bryman, 1984), and ‘garbage can’, organised

anarchy and organic (Cohen et al, 1972) models of innovation and decision

processes found in the ‘classic’ organisation studies literature of the 1970s

and 1980s. The garbage can model was developed to explain the patterns of

decision making and innovation in organisations that experience extremely

high uncertainty. Cohen, March and Olson, the originators of the model,

called the highly uncertain conditions an ‘organised anarchy’ This is caused by

three characteristics:



1 problematic preferences

- goals, problems, alternatives, and solutions are ill-defined; ambiguity

characterises each step of a decision or organisational change process

2 unclear, poorly understood technology (which we would widen out to all

systems and ask whether it might apply to all innovations)

- cause and effect relationships within the organisation are difficult to

identify; an explicit database that applies to decisions is not available

3 staff turnover

- in addition, staff are busy and only have limited time to allocate to any

one problem or task; participation in any given decision will be fluid

and limited.

Some of these conditions clearly applied to many, if not all, of the TCs we

have studied over the last three years (for example, the often ambiguous

nature of the relationship between a TC and its host trust or the high turnover

of senior staff in many of our case study sites), while others seem less

applicable, and there are some that need to be added to take account of the

peculiarities of the TC and, perhaps, health care innovation in general.

Nevertheless we believe that many local mangers who have been intimately

involved in the TC programme would recognise the garbage-can model.

The general point that does seem to apply here is that there is huge

looseness, randomness and disconnection in an organisational innovation

process like this, the outcome of which is determined by when, where and

how streams of problems, potential solutions, participants and choice

opportunities come together and match-up (or not). Hence, the decision

making that led to the TCs is like a large garbage can in which these streams

are constantly being mixed. When a problem, solution and participant happen

to connect at one point, a decision may be made and the problem may be

solved; but if the solution does not fit the problem, the problem may not be

solved.

Thus when viewing the organisation as a whole and considering its high level of

uncertainty, one sees problems arise that are not solved and solutions tried that

do not work. Organisation decisions are disorderly and not the result of a

logical step-by-step sequence. Events may be so ill defined and complex that

decisions, problems, and solutions act as independent events. When they

connect, some problems are solved, but many are not

(Daft, 1995; p.381).

The garbage can metaphor was chosen deliberately by these authors and is

not an attempt at humour but to challenge the rational model embraced by

(in their view) most change strategists and managers. And we suggest that

this applies in health care too:

The contents of a real garbage can consist of whatever people have tossed into

the can. A decision-making garbage can is much the same. The four streams –

choices, problems, participants, and solutions – flow toward the garbage can.

Whatever is in the can when a decision is needed contributes to that decision.

The garbage can model sees decision-making in organisations as chaotic:

solutions look for problems to solve, and decision makers make choices based

on the arbitrary mix of the four streams in the garbage can.

(Champoux, 1996; pp.403-404; see Figure 38)



Figure 38 Garbage-can model

Source: Champoux, 1996

Most of the above theory focuses quite narrowly upon organisational decision

making, so a question that needs to be asked is whether it might also apply

to organisational innovation and service development processes in the wider

‘change’ sense, and does it apply more widely than TCs? It is beyond the

scope of this report to consider that question in detail.not least because one

would need to consider in some detail other models of problem solving,

decision-making and change found in the organisation studies literature,

including the rational model, bounded rationality model and ‘muddling

through’. However, as we have suggested there are many features of the TC

story that would fit the garbage can model. This is particularly evident when

one reviews the almost serendipitous confluence of local factors that led

(Sections 3 and 4) to the decisions to open the TCs. One can point easily to

the four streams of:

1 problems

- the need to be competitive, to improve throughput, to refurbish a

building, to tame the orthopaedic surgeons

2 choices

- a new ward? a larger day-unit? a change in outpatients? a TC? a deal

with the independent sector?

3 solutions

- acquire new funds to build a TC, send elective patients elsewhere,

import foreign surgical teams; introduce nurse practitioners

4 participants

- a sceptical chief executive replaced by an idealist; a nearby trust

deciding to send and then not to send patients, an SHA being able – or

not – to encourage patient flows to the TC.

However, the picture is not so straightforwardly just one of serendipitous

mixing of the contents of a bin. There was also a large measure of intelligent

ongoing sense-making and the very skilful use of the decision-making process



to steer the innovation forward on whatever seemed the best available

course. We need therefore to consider not only how people arrive at decisions

or make plans, but also the follow-on question of how people might manage

an organisational innovation like a TC in conditions where there is this

random mix of influences, and where they lack the power or capacity to

analyse, prioritise and make rational choices via an explicit path. This

becomes an especially interesting question in a formal bureaucratic context

such as an NHS hierarchy that does not allow for, or would probably deny or

strongly disapprove of, this conception of reality. Behavioural theories have

portrayed organisational actors as the ‘puppets on a string,’ the helpless

plaything of social forces, the corks bobbing on a mighty sea – coping, trying

to keep their heads above water, surviving rather than managing. Yet we

found very little evidence of this among NHS managers dealing with an

organisational innovation whose very nature was a messy, unpredictable and

uncontrollable process where normal rational planning assumptions and

disciplines did not apply. Rather, our impression was of some quite artful

skippering of a vessel that was being tossed about by the ever changing

winds and currents. In other words, although the senior staff in TCs have

been buffeted by the constant changes, they (at least those that didn’t fall

overboard) have coped very well, many – thought not all – thereby helping

their TCs to survive the storm.

The way the TC innovation has been managed in the NHS had strong

elements of Lindblom’s (1959) description of ‘muddling through with a

purpose’, which is as much science as art. Just as anyone could learn to swim

so too, he said, could they develop the competence and ‘recipes’ to survive,

grasp opportunities, and ultimately reach dry land. Certainly the ‘science of

muddling through’ has been very much in evidence throughout our study of

TCs, but we prefer also to emphasise the power and potential of human

agency to overcome, even tame, these hostile conditions. What we have seen

in most of our sites is people ‘acting back,’ enacting their own environment in

the Weickian sense (Daft and Weick, 1984; Weick, 1995), all of this with an

almost heroic tenacity.

This view of innovation to which we are pointing does not reject the

description of complex, almost chaotic organisational reality, but reveals a

different response to it by the actors and participants. In the face of

adversity, they do not give up or even settle for muddling through or ‘hanging

on in.’ Rather, they reveal high levels of positive energy and resolve and

begin to work and pull together – almost in direct proportion to the height of

the mountain to be scaled or wave to be conquered. Positive organisational

scholarship (Cameron et al, 2003; see Section 10.4.3) would therefore give a

rather different ‘take’ on processes of organisational innovation from the

classic one of powerlessness and fallibility, one that is characterised by

resilience, virtuousness, care and commitment, loyalty, optimism, respect,

tenacity, even forgiveness. It focuses on the kinds of ‘transcendence’ and

‘positive spirals of flourishing’ (ibid; p.4) that approach the best of the human

condition.

In our case study TCs we have observed many of these qualities, and while it

does not always presuppose a good outcome, it does describe a positive side

to the process that needs to be included in our conception of the management

of innovation processes. The fact that this may happen in one TC and not



another would lead us to consider some of the underlying dynamics in

virtuous and vicious cycles of innovation. The new theory implied by this view

might also explain the ‘ingredient’ that gets people out of the ‘garbage’ and

into a better place.

10.4.3 Conceptualising key success factors in health care

innovation processes

In order to identify some of the key success factors in innovation and change,

and to use these to evaluate the story to date of our TCs, we finally turn to

Greenhalgh et al (2005) who recently developed a model for analysing the

emergence and diffusion of organisation-level innovations (like TCs). The

model was developed by means of a systematic literature review on the

diffusion, spread and sustainability of innovations in the organisation and

delivery of health services, and was tested by its authors on four case

studies: integrated care pathways, GP fundholding, telemedicine and the

electronic health record. As the originators of the model caution: ‘we are

conscious that in presenting a… model of a complex reality, we risk

encouraging a formulaic, ‘checklist’ approach in which arrows connecting

different components are erroneously interpreted as simple causal

relationships that can be controlled and manipulated in a predictable way.

This, of course, is not the case’ (ibid; p.199). Rather ‘the model is intended

mainly as a memory aide for considering the different aspects of a complex

situation and their many interactions’ (Greenhalgh et al, 2004; p.594).

The authors pose nine questions with which to prompt reflections about the

diffusion and implementation of an organisational innovation (Greenhalgh et

al, 2005; p.200):

1 What were the features of the innovation as perceived by the intended

users (and also, separately, by top management and key decision

makers in the organisation)?

2 What were the features of the individual adopters and the

adoption/assimilation process?

3 What was the nature of communication and influence that drove the

diffusion/dissemination process?

4 What was the nature of the inner (organisational) context and how

conducive was this to the assimilation and implementation of innovations

in general, and this innovation in particular?

5 What was the nature of the outer (environmental) context and how did

this impact on the assimilation process?

6 Was the implementation and institutionalisation process (as opposed to

the initial adoption process) adequately planned, resourced and

managed?

7 What were the nature, capacity and activities of any external agencies?

8 What was the rate and extent of adoption/assimilation of the innovation,

and to what extent was it sustained and developed? If these are

considered as the dependent variables, to what extents do the answers

to questions 1 to 7 explain them?

It may seem odd to use these questions to attempt a general review of the

implementation of TCs as ‘an’ organisational innovation, given the wide



variation we found among our sites. In doing so, however, we believe we can

draw out some wider insights into the management of organisational

innovations more generally. Both here and in Appendix 8 (which gives more

detail) we organise our responses to these questions (seven in total as we

subsume question 5 into question 4), which reflect the main components of

the model:

• as an organisational innovation a TC has a number of key attributes

which research suggests would point to a high adoption rate.

Importantly, TCs have a relative advantage which is readily apparent and

accepted to be high by virtually all users (in this context, GPs and PCTs

as well as end users) and which is compatible with the value system of

most NHS staff (that is, the provision of fast, reliable and efficient

treatment and improved care for patients). It also had a number of less

explicit positive attributes such as its usefulness as a vehicle to challenge

entrenched professional roles. This general consensus as to the inherent

value of the innovation may explain why – allied to a strong central

directive (see below) and their high potential for reinvention locally – TCs

appeared so rapidly and in greater numbers than originally anticipated.

While the concept of a TC is easy to understand and accept, it is

nonetheless a relatively complex innovation to implement, requiring

multi-professional and multi-disciplinary working from a variety of

individuals and teams (themselves operating within already complex

organisations), as well as wide ‘buy-in’ from a variety of external

stakeholders. And it always had the potential to stimulate resistance,

both from professionals who felt threatened by the changes it brought,

particularly when TCs became associated in many minds with a

perception that they were (by association with the private sector)

undermining some deeply-held NHS values.

• in terms of the adoption and assimilation of TCs – as we have discussed

in Sections 3 and 4 – the characteristics as well as the meaning of TCs to

the potential adopters(that is, the senior managers and clinicians

involved in the adoption decision process) were very varied. We would

define the adoption decisions as typically authoritative as opposed to

collective (in that individuals in organisations were told to adopt, rather

than everyone in a particular group deciding to adopt). However the

adoption processes tended to be ‘complex, iterative, organic and untidy’

rather than a single event (see Greenhalgh et al, 2005; pp.11-12). A

range of views among the potential adopters at each site (idealists,

opportunists, pragmatists and sceptics, as well as conflicting interests

around professional roles and status) reduced the likelihood of collective

adoption decisions within any given site. Financial (and to a lesser

extent) governance concerns have typified the concerns of adopters at all

stages of the assimilation of TCs into NHS organisations; these have

caused uncertainty and impacted on the ability of local leaders to

continuously adapt to the ever changing circumstances surrounding TCs.

• research evidence suggests that where innovations have been introduced

as formal developments (as in the case of TCs via the NHS Plan), their

diffusion tends to be via vertical dissemination networks (and is often

therefore planned strategically). Certainly, NHS TCs did spread mainly

via vertical networks but later their spread was also influenced by ‘lateral’

connections, particularly when NHS trusts saw TCs as an opportunity to



achieve any number of local objectives and reacted accordingly. Most

often, trust clinicians and senior managers – including chief executive

officers - were the ‘opinion leaders’ (although often not all clinicians were

supportive and some were hostile to the innovation).

• the inner context (referred to in Section 3 as the internal milieu) was

such that virtually all TCs were introduced into large organisations with

high degrees of specialisation, functional differentiation and

professionalisation but typically with few slack resources and limited

ability to manage a long-term organisational change process and to

evaluate it over time. The research evidence suggests that such

organisations will assimilate innovations more readily, although such

characteristics together account for only 15 per cent of the variation in

‘innovativeness’ between comparable organisations (Greenhalgh et al,

2005; pp.11-12). Following the observation made earlier in this section

(based on Pressman and Wildavsky’s 1973 research) the early planning

and building phases of TCs were typified by strong project management

(utilising pre-existing strengths of clinical expertise and capital projects

management) but this close project management typically ebbed away

after the opening of the facilities. The complex, shifting management

agenda, often entailing conflicting goals as well as increasing competition

for management time, reduced the organisations’ absorptive capacity.

Although the basic premise of separating elective and emergency care

fits very well with prevailing views as to the future configuration of acute

services, the training and other system-wide implications of TCs were

often not thought through by adopting organisations at an early enough

stage.

• the outer context (Section 3’s ‘external milieu’) was characterised by a

very strong central, top-down drive to encourage (at times, insist upon)

the adoption and spread of TCs (reinforced by national performance

targets), all of which encouraged the early uptake of this innovation. This

contrasts with some other recent innovations in health care; for example,

integrated care pathways which initially arose peripherally and were

spread informally via the professional networks of clinician enthusiasts

(Greenhalgh et al, 2005; p.203). However the viability of at least some

TCs has been undermined by apparently conflicting national policies,

some of which (the expansion of private sector provision for example)

have been controversial both within and outside the NHS.

• features of the implementation and institutionalisation process included

significant recruitment and/or training in the early stages and strong

reliance on influential enthusiasts and supporters (particularly among

clinicians). Middle managers in the ‘host’ trusts were sometimes not well

disposed to what they saw as the freedoms and opportunities afforded to

their contemporaries in the TCs. However they also saw the benefits of

the innovation in helping them to meet targets such as waiting times and

patient throughput, and in challenging entrenched clinical traditions.

Although some TCs have established outcomes measurement as a core

activity – and all conduct patient satisfaction surveys – there is little

strategic assessment of their impact on wider health care systems (and

most have poor internal IT systems). This is important as research

suggests that accurate and timely information (through efficient data

collection and review systems) on the impact of the implementation



increases the chance of successful routinisation (Greenhalgh et al, 2005;

p.15).

• finally, as far as the role of external agencies was concerned, although

significant funding was made available for capital projects, central

support for addressing the challenges of implementation was more mixed

and piecemeal, and fell away to a significant extent after the demise of

the Modernisation Agency. And as our analysis showed, often the

meanings attached to TCs by external agents (the Modernisation Agency,

Department of Health, SHAs etc) were at odds with those attached by TC

managers and staff.

So what does this overview of TCs as an organisational innovation tell us

about how such innovations might be managed in the future? Firstly, that

even a combination of (a) high relative advantage (even when it is widely

acknowledged), (b) close compatibility with the values, norms and perceived

needs of adopters and (c) a high potential to adapt, refine and modify an

innovation is insufficient to guarantee the successful implementation and

spread of a complex organisational innovation. Rather, our findings seem to

confirm that it is the interaction between an innovation, its intended adopters

and its context that determines the adoption rate and the success or

otherwise of its local implementation.

Secondly, although the early diffusion of organisational innovations can be

accelerated by a strong top-down policy directive (and given further weight

by means of capital funding, central facilitation and powerful local champions

in the form of senior clinicians and trust chief executives), successful

implementation of such a directive requires consistent strategic and front-line

change management skills which are often in short supply in the NHS. Where

the organisation’s existing knowledge and skills base is insufficient, then the

use of external change agents to support implementation requires a common

language and values system, and shared meanings. As we have argued in

this report, and as Greenhalgh et al (2005; p.9) reinforce, ‘if the meaning

attached to the innovation by individual adopters is congruent with the

meaning attached by top management, service users and other stakeholders,

assimilation is more likely’. This was not always the case with, say, the

Modernisation Agency. External facilitation of networking and collaboration to

support adopters should explicitly acknowledge and address the not only

common implementation challenges but also the pervasive contests of

meaning.

Thirdly, although many of the typical structural characteristics of a large

acute hospital (with its specialisation and functional differentiation) should

increase the likelihood of the adoption of organisational innovations, the

typically limited – or absent – ‘slack resources’ in NHS trusts reduces the

receptivity and hence the assimilation of the innovation. This lack of internal

resources again points to the potentially important supplementary role of

external networks and practical support.

Fourthly, conflicting parallel policy initiatives and resulting uncertainty can

militate against the ability of those leading implementation at the local level

to respond as adaptively as they would like (especially if such initiatives are

controversial and have mixed support).



Fifthly, implementing complex organisational innovations that cut across pre-

existing organisational boundaries (both at the local and regional level)

requires a greater focus on the issue of ‘connection’ both vertically and

horizontally – particularly if the NHS is to operate as an ‘innovation system’

rather than a loose collection of fragments. Such connectivity will be at

increased risk if the Department of Health succeeds in its intention to

introduce a policy environment that is based less on top-down directives and

more on patient views and local incentives (see Section 10.3.1; Figure 35).

Finally, our analysis of TCs suggests that both the ‘planning’ and ‘complex

system’ perspectives (as summarised in Table 8) have weaknesses and

omissions but it is in the discrepancies and differences between the two that

we may find some important lessons for managing organisational innovations

(as others have previously discussed in much more detail than we are able to

do here). For example, Poole and Van de Ven (2004; p.395) point out that,

while it would be a mistake to complicate our thinking simply for the sake of

complexity, ‘it is through the dialectic between simplification and

complexification [sic] that our understanding of change and innovation

processes will ultimately advance’. Seo et al (2004; pp.101-2) argue that

‘dualities’ (polar opposites that work against one another) can help to ‘draw a

realistic picture of planned organisational change, particularly its complex and

dynamic nature... [Acknowledging and valuing dualities and tensions] may

increase practitioners’ awareness of various hidden but essential dynamics

associated with organisational change and its consequences’. In the case of

TCs, one limitation of the ‘rational, linear planning model’ of innovation is

especially unsuited to ‘volatile environments’ (Augustine et al, 2005) that are

not stable, known or consistent, not least because they were never designed

for change but for maintaining order. Many in the NHS would argue that they

are experiencing a more ‘volatile environment’ than ever before, with so

many structural and leadership changes, and so many unknowns, such as the

involvement of the private sector and the introduction of Patient Choice. And

any innovation itself adds to this ‘volatility’. If this is the case, the rational

model will always be found wanting, no matter how skilled people are in its

use. Equally, the second, complex perspective is on its own unlikely to be

effective, leading to missed targets, drift and growing resentment among

other stakeholders about the lack of knowledge, co-ordination and an overall

systems view. In a similar vein to our earlier point about design rules,

Eisenhardt and Sull (2001, as cited in Balogun and Johnson, 2005; p.1596)

argue that:

In highly dynamic or complex conditions senior managers cannot be expected to

‘know’ all that is happening. Top managers should therefore focus on the

development of simple rules, for example regarding expected outcomes or

boundary conditions, which set the limits within which other organisational

actors have to interpret what makes sense and what should be done. In

situations of change, too, actors similarly have to translate top-down intent in

the context of their own realities. This suggests that ‘managing’ change may be

more to do with senior management striving to deliver clarity of purpose,

expected outcomes and boundary conditions, and a shared understanding of

these, rather than trying to manage the detail.

This also brings us back to our earlier point that ‘implementation cannot be

divorced from policy’, with the implication that organisational innovation

needs a judicious mix of the planning and complexity views of policy making

and implementation. One needs plans and controls (more than we found in



our study) but – and this is the important point – only for those things that

you can plan and control. But one also needs processes and skills that can

deal with all the emergent, unpredictable aspects of the innovation

implementation process (which again were not greatly in evidence in our

sites); what we might call ‘agile innovation.’ We would suggest that the NHS

needs if anything to look much more closely at the complex systems

perspective for it begins to reveal the relatively unexplored aspects to

organisational innovation in the NHS and also seems increasingly well-suited

to the new and emerging policy context with its emphasis, so characteristic of

complex systems, upon self-managing and self-improving.

10.5 Practice implications of the research

10.5.1 For policymakers

1 Top-down target-led central innovations will inevitably be re-crafted at

the local level to suit local needs and build on existing initiatives; they

need therefore to retain appropriate flexibility (headroom) if they are to

be crafted while still successfully fulfilling their core objectives.

2 Policymakers should try to facilitate local innovation using ‘design-

principles’ that acknowledge the likelihood that rational planning of

innovations will be limited in both its feasibility and its applicability in the

‘volatile environment’ of NHS management.

3 There should be more rigorous evaluation of innovative policies while

they are on the drawing board, and where this reveals strong evidence –

for example from modelling techniques – that problems will arise from

the widespread implementation of an innovation, caution should be

exercised.

4 Assessments of the likely impact of new policies on those that are

already working their way through the system should be undertaken

before a new policy is introduced nationally.

5 Even where an organisational innovation has all the attributes of likely

success (for example it is widely acknowledged to have high relative

advantage; it is apparently compatible with the values, norms and

perceived needs of those who are expected to adopt it; and it has the

potential to be adapted to a range of local requirements) there is no

guarantee that it will work. It is also necessary to explore very carefully

the potential interaction between the innovation, its intended adopters

and its context when assessing the likelihood of successful

implementation.

6 Specific training may be required among managers at all levels of the

NHS, as successful implementation of organisation-wide innovations

require a high level of both strategic and front-line change management

skills, which are often in short supply.

7 Where the organisations’ existing knowledge and skills base is

insufficient, then the use of external change agents to support

implementation may be required but is unlikely to succeed unless there

is a common language and values system, and shared meanings between

the policymakers, the facilitators and the front-line innovators.



10.5.2 For change leaders and management practitioners

Service innovation is a social and organisational process, which means that

the management of innovation is predominantly an issue of managing the

social and organisational factors associated with that process. Below we have

identified and detailed – under seven headings – 74 such factors that arose in

our research; these are presented in the form of ‘design principles’ (Romme,

2003; Van Aken, 2004, 2005a, 2005b) for service delivery innovation (with

cross-references back to the main text). The points in 10.5.1 also apply here,

particularly the fifth.

Dealing with complexity, non-linearity and unpredictability

As we have discovered during the course of this research, the innovation

process is characterised by high levels of complexity, ambiguity, uncertainty

and unpredictability (see in particular Section 6 and Section 10.2), and no

amount of planning and attempted control is ever likely to change or

compensate for that. Therefore it is better, we believe, to take steps that

allow change practitioners to work ‘with’ these forces rather than infinitely

wrestling to tame and get on top of them. The management of complexity (as

opposed to the resolution of complexity) is thus core to the process and

practice of innovation. Therefore the following points are recommended:

1 Keep the portfolio of innovation initiatives to a manageable size; do not

try to chase everything that appears (as, for example, did Site C);

‘informed opportunism’ is about making felicitous choices not chasing

every management fad or fashion that passes by.

2 Ensure that there is a concise, evidenced and cost/benefits-based

business case for the innovation with a clear vision, aims, finance

forecasts and objectives (especially around elements such as capacity

and demand estimates, skill-mix, case-mix and volume projections, key

performance indicators and competitor analysis). Remember that three

TCs in our study ‘failed’ because there were simply not enough patients –

the business case had been built on hugely over-optimistic demand

assumptions. Also be clear and upfront in the case about motives,

aspirations and intentions. This is your ‘workable blueprint’ (Van de Ven

et al, 1999) or ‘frozen ambitions’ (Van der Knaap, 2006). Being a

relatively fixed point it will provide the North Star for the innovation

journey – especially helpful when (inevitably) you find yourselves blown

off-course or in stormy waters. Business and strategic planning of this

kind needs to take precedence over detailed operational planning, which

can itself become an increasing burden and source of anxiety when the

‘reality’ begins to diverge (as it surely will) from the plan.

3 To address the above, roomy, adaptive (as opposed to detailed, hard-

wired) strategic plans are needed – directional rather than detailed but

addressing all the key strategic ‘choice points’ for innovators, such as (for

example in the case of TCs): single specialty or mixed specialty; how far

the innovation is about ‘improved efficiency’ or ‘improved experience’;

how clear and complete the separation will be between emergency and

routine elective treatment; the choice between day case or short stay;

the extent to which the TC will operate as an autonomous, stand-alone,

ring-fenced ‘hospital within a hospital’ or as an ‘extension’ of the main

hospital (Section 6.5.4); whether there should be diagnosis and



treatment (‘one stop shop’) or one or the other; and whether the TC

should be virtual or real

4 In this kind of unpredictable innovation environment, ‘preparation’ is as

or more important than ‘planning’ – people often plan because they are

not properly equipped or prepared (in terms of skills, resources, shared

vision, team effectiveness, motivation and direction); or put the other

way round, the more prepared (‘match fit’) you and your team are the

less you may need to plan in huge amounts of detail.

5 Do wider horizon scanning to pick up any distant clouds that might put

future projections at risk, for example Patient Choice and Payment by

Results (Sections 6.2.2 and 6.2.3), changes to GP commissioning,

involvement of the independent sector (Section 6.2.1), mergers and

reorganisations, closures (see Section 5 for further examples and their

impact).

6 Flexible ‘physical’ design to accommodate future innovation in both

equipment and procedures (especially when there is the danger of

‘building the wrong thing in haste’ (see Section 2.3). In the context of

the ‘pressurised planning’ (Section 6.1.2) that surrounded TCs, this

concept of flexible design needs to go beyond physical buildings to

embrace many other aspects of the innovation process, including the

organisational and management dimensions (see Site E, Section 6.4.2,

for an example of effective flexibility).

7 Avoid drowning in detail by focusing on key aspects of care, core

measures and ‘dashboards’, and measuring only the ‘meaningful stuff’.

8 Encourage small-scale innovation experiments and develop and test

various prototype solutions before spreading system-wide (it is worth

noting that, in this vein, the Department of Health suggested leasing a

facility to see how it works out but we are not aware of anyone actually

having done that).

9 Build in flexible contingencies and formulate and rehearse multiple and

explicit ‘imagine if’ scenarios.

10 Try to develop, dry-run and test performance measurement, scheduling

and planned booking, information and other systems in advance of ‘going

live’ – the notion of carrying out test flights for fledgling or early

innovations.

11 Do not concentrate on designing and planning to the detriment of

implementation and ‘trying out by doing’ – making ‘test flights’ as

opposed to trying to work it all out ‘from the ground’. Building to pilot

and test, learning faster by failing early and giving permission to explore

new behaviours are likely to be more productive than trying to theorise

about and plan for everything in advance (Coughlan, Fulton Suri and

Canales, 2007). To some extent this runs counter to what the

Modernisation Agency was advocating in the way of TCs having detailed

operational plans. See quotation from Site B in section 4.1.2 for an

example of effective enactment and enabling activity.

12 Improvisation and improvisational behaviour warrant a special mention

in this practice category. There is growing evidence of extensive use and

acceptance of improvisation in the management of change and

innovation, not because it is fashionable or even necessarily creative but

because it is the only way of coping with complexity and fast change, and



the flexible behaviour and spontaneous decision-making these require

(Leybourne, 2007; Chelariu et al, 2002; Crossan, 1997). Improvisation

activity therefore needs to be built in to the innovation process and also

developed as a core competency by those involved.

13 Finally it is important not to give the impression that absolutely

everything associated with the innovation process is unfathomable,

unpredictable and unplannable. Much of it is but a lot of it is not.

Currently a good deal is not being (fore) ‘seen’ simply because the

planning ‘instruments’ being used are insufficiently sensitive or accurate

for this to happen. In contrast to the rather crude intuitive planning and

scheduling methods in current use in TCs, our research shows that there

is huge potential for even fairly conventional mathematical modelling and

analytical tools to be deployed so as to reveal the many things that can

actually be analysed and predicted, and hence to narrow the gap

between what is currently known and could be known (for example

predicting capacity requirements, optimising patient flows and bed

capacity, deciding whether a TC will improve the efficiency with which

capacity is utilised within the local health community, managing

variability - see Sections 8 and 9). Practitioners therefore need to

differentiate between what is genuinely unknown and unknowable, and

that which could be known if they knew how and where to look.

Creating ‘enabling’ structures and systems

Structure is the ‘skeleton’ for the innovation process, its purpose being to

connect all the various roles together and to provide the necessary functional

coordination between them. Structure does provide a mechanism of control

and accountability during innovation and change but its main purpose is to

enable new roles, behaviours, processes and patterns of behaviour to emerge,

develop and ultimately intertwine and work as a system.

1 Establish a core multidisciplinary, preferably multilevel, innovation team

(a ‘core of like minded people’ – Site B, Section 3.1) and take sufficient

time to develop a shared aspiration and unity of purpose between its

members. One of the first activities should be to vigorously challenge the

initial claims and assumptions contained in the business plan which often

turn out to be well wide of the actual mark (Section 6.1).

2 Clearly define all key roles and line responsibilities of those involved in

the innovation process.

3 Establish complete transparency in staff recruitment and avoid

favouritism (Section 6.5.1); try to anticipate where staff shortages are

likely to be and where alternative arrangements may need to be put in

place (Section 7.2.3).

4 Clarify and agree gradings and new terms and conditions sooner rather

than later – get the ‘structural basics’ sorted out.

5 Establish robust project management processes but avoid the heavy

hand of old, ‘soviet-style’ administrative structures that take away the

energy, enthusiasm and resilience of those involved, and bring about

premature ‘death by project management’.

6 Organise around clear and agreed treatment protocols and care pathways

(see Section 7.2.2 for the details and challenges of doing this) – in other



words do not organise in the abstract but tie structures in to clinical

processes.

7 Be aware of the need to create new or extended roles that cross

traditional boundaries, for example schedulers, extended roles for

therapists (Site B, Section 4.1.2); advanced nurse practitioner (Section

7.2.3), new assistant practitioner and anaesthetic practitioner roles

(Section 7.2.2); constantly challenge the logic of traditional structures,

seeking not just alterations but real alternatives (Section 7.3).

8 Create ‘slack’ for people to grow into these new roles and don’t accept

the view of innovation as ‘overtime work’ on top of normal duties which

can only be sustained for a limited time (see Site G, Section 3.1).

9 Establish linking and liaising roles (for example clinician managers,

service innovation team) – vertical, horizontal and diagonal!

10 Start early to build a marketing and communications strategy (Section

6.4.3), structure and process (see Section 3.2 for importance of

‘meticulous communication’).

11 Endeavour to maintain continuity in key staff positions by recognising

and rewarding accordingly (see Section 6.5.2).

12 Clear targets (key performance indicators) and incentives for

performance (for example waits and length of stay), safety and

experience.

13 Attend to and put in place clinical and governance arrangements well in

advance of opening.

14 Agree – and enforce – strict protocols for patient selection, and inform all

relevant parties what these are.

15 Ensure adequate levels of IT and information support are available from

the outset, especially in relation to booking systems (Section 6.5.3).

Navigating the politics of innovation and securing stakeholder

engagement

NHS service delivery innovation requires collaboration between multiple

professional and occupational groups and thus involves complex political

challenges in ‘uniting them in thought’ and getting them lined up behind the

TC (Section 6.5). Innovation is constantly threatened by antagonistic

relations between key players (Section 6.3.2) and constant attention

therefore needs to be given to building and maintaining the (highly fragile)

‘negotiated order’ (Section 3.4).

1 Engage, inform and involve the senior executive team, board and (where

applicable) members council from the outset – and keep them involved.

2 Clarify relationships and interdependencies between units, departments

and the wider organisation (especially ‘freedoms’ around the TC/trust

relationship; Section 6.5.4); resist the natural drift into adversarial

relationships, derogatory stereotypes and damaging ‘them and us’/win-

lose dynamics.

3 Trust needs a special mention in this category: this research has shown

repeatedly that once trust has broken down or been violated (especially

between a hospital trust and its community ‘partners’) the success of the



innovation will be in serious jeopardy (for example Site F, Section 6.4.1;

Sites C and G, Section 6.4.2).

4 Align unit innovation strategy to wider organisational and SHA strategies

– for example so that it fits in with ‘local development plans’ Section

3.2); at the same time there should be ‘no surprises’ for any of the key

stakeholders.

5 Address the ‘what’s in it for me’ (called the ‘motivators’ in this report) for

all key groups crafting and framing the ‘case’ to suit and connect with

local agendas and ideals and the ‘things that need fixing’ (efficiency and

quality concerns; hospital regeneration (Section 3.1), improved working

life – things that managers, clinicians and patients would see as the

benefits or ‘relative advantages’); for example tapping in to the ‘things

that worry and attract doctors’ (Section 3.1). Different frames will be

required for opportunists, idealists, pragmatists and sceptics (Section

3.4) and for managers and clinicians; see section 4 in particular for

detailed examples of the different motives at play; these divide roughly

into:

a quantity, performance, efficiency, revenue, resources (especially

appealing to managers but the latter also to clinicians)

b quality, experience (especially appealing to clinicians)

c kudos (especially appealing to senior figures).

6 Incentives and rewards are still one of the most powerful ways of getting

innovation adoption; these can be financial or non-financial (Section

7.2.3).

7 Find local innovation champions and leaders and empower them to take

responsibility for getting their particular professional colleagues on board

(Section 7.1) – the ‘like recruits like’ homophily principle

8 Listen to the sceptics; they are often voicing the concerns of the silent

majority.

9 Deal with opponents and adversaries by including them in the innovation

process; leaving them out is only likely to increase the bickering, hostility

or opposition (see Site E, Section 3.2).

10 Develop new care pathways and models of care with those who are

supposed to be adopting and following them and avoid imposition.

11 Look for ‘catalytic’ and ‘piggy-back’ events for promoting the innovation

and winning the support from internal and external stakeholders.

Building the innovation network

Innovations like a new TC are as much a ‘social’ community and network-

building enterprise as a ‘technical’ project, depending for their outcome on

the assistance and support of a wide range and number of interested third

parties. It is essential to ensure in the main that these are ‘helping hands’ not

‘hindering hands’.

1 Don’t try to foist your TC on the wider health community: make dialogue

and dense face-to-face interaction an external as well as internal feature

of the innovation process.

2 Build and nurture close and constructive relationships with local health

community partners, including GPs (innovation is about building

relationships, especially trust).



3 Also build direct links with community groups through meetings and

consultation exercises, and involve representatives on key meetings.

4 Search out possible strategic partnerships and alliances (including

independent sector).

5 Link with specialist external groups and make use of the expertise,

protection, and networking capacity of agencies like the Department of

Health, the Modernisation Agency, the NHS Insitute for Innovation and

Improvement (Section 2.3.1) or NHS Elect (Section 5.5).

Creating a learning process

Innovation and change processes are also learning processes – thus ‘no

learning no change’. ‘Learning’ in this regard needs to address the harder

knowledge and skills issues as well as the softer awareness-raising and

developmental issues.

1 Treat the innovation as an ongoing individual and group learning and

development opportunity (Section 7.2.4).

2 Create from day one a parallel formative/developmental ‘evaluation for

learning’ stream alongside the innovation process, so that events and

experiences can be learned from and a continuous cycle of

reflection/improvement/refinement established.

3 Use this and other opportunities to raise process awareness and

challenge conventional assumptions about the nature of innovation and

change (for example whether patients – and clinicians! (Section 6.5.1) –

would be prepared to travel to a different provider for treatment –

Section 6.4.3).

4 Encourage internal and external (action) research of aspects of the

innovation process.

5 Be aware and ‘design for’ possible unintended consequences or ‘spin offs’

from the innovation (positive and negative – for example resentment and

hostility from the wider trust; Section 3.1).

6 Identify any skills gaps early on and address these by way of dedicated

training and development programmes. Such programmes will cover

skills training but also behavioural, attitudinal and mindset issues (cf.

Site C, Sections 4.1.2 and 4.1.3).

7 Treat setbacks as opportunities for learning (not blame).

8 Hold regular all-staff review days and away days.

9 Seek opportunities to embed a ‘culture of questioning’ within the

innovation process.

10 Encourage members of the core team to attend specialist workshops and

conferences (for example Ambicentres International) and visit other sites

(knowledge exploration and exploitation is crucial to the innovation

process).

11 Look for and take advantage of any free expertise in the system, for

example the Modernisation Agency (Section 2.3.1) and its successor, the

NHS Institute for Innovation and Improvement

12 Obtain regular feedback on improvements (or not) in both patient and

staff experience; establish a network of trusted informants.



13 Conduct a summative (‘how did we do’/‘learning for judgement’)

evaluation at discreet stages of or at the end of the project to capture the

lessons retrospectively and build them into a set of design principles for

future innovation (‘if you want to achieve outcome Y in situation S,

something like X might help’).

14 Improvisation is also a powerful learning mechanism (see Section 10.5.2

(point 12) on ‘learning to improvise, improvising to learn’), as is

prototyping and pilot testing.

Changing behaviour and culture

Innovation is about changing mindsets and behaviours so that people ‘think

and do’ in different ways. As our research confirmed it is very easy for an

innovation attempt to become mired in the traditional ‘way we do things

around here’ and to end up more of a replication than an innovation. It is said

that culture is like ‘gravity’: you only feel it when you try to jump six feet in

the air. Clearly all the sites experienced these normalising or gravitational

effects of the trust culture, although some were ultimately more successful in

getting in to orbit than were others (Section 7.3).

1 Try to develop an awareness of the inhibiting ‘brake effects’ of existing

cultural practices and traditional mindsets; constantly challenge the

common sense in which culture meanings are wrapped; approach the

culture more as an outsider than a native; because in the case of culture

‘the fish is the last to see the water’. Use outsiders, including patients

and carers, to reflect back how they see and experience the culture.

2 Focus on building a unique and distinct identity for the TC that patients

and staff can relate to and value, and an image that ‘badges’ and brands

the ‘product’ and establishes its unique selling point and attracts

attention and support in the wider field. Decide whether to call your TC a

TC or not (labels do matter), and discuss whether staff loyalties should

be primarily to the TC or to the wider trust.

3 Also concentrate on developing a strong and supportive ethic or ‘ethos’

around the TC (for example Site G, Section 3.2), for example stressing

openness, honesty, treating staff and patients with dignity and respect;

striving for excellence, listening and encouraging feedback and so on

(Section 3.1); or giving treatment based on the ‘wellness’ rather than

‘illness’ model (Section 3.1), and guaranteeing continuity of care (Section

7.2.3).

4 Hold opening ceremonies and official launch events as a symbol of the

importance being attached to the innovation.

5 Award other symbols of recognition for service excellence, for example

TC nurse of the year award, chair’s award.

6 Value and reward ‘thinking outside the box’ and resist attempts to

normalise and reincorporate the innovation back into the normal frame of

‘the way we do things around here’.

7 Concentrate on building a strong, team-based, entrepreneurial ‘just go

do it’ culture or ‘can do mentality’ like that which was evident in a

number of TCs (Section 7.2.4).



8 Value and reward good ‘citizenship’ behaviours within the TC (that is,

support activities that go beyond the normal call of duty) for example

Site F clinical manager, Section 7.3.

9 Reward and celebrate achievement.

Leadership

• Look for emergent and rising leaders rather than the ‘usual suspects’

(‘use the same old horses and what you get is the same old glue’).

• Adopt as far as possible a ‘help it happen’ as opposed to ‘make it happen’

or ‘let it happen’ approach (Section 10.1; Figure 35, Section 10.3.1).

• Move from a rule-based to an incentive-based form of leadership: ‘pull’

rather than ‘push’ leadership.

• Ensure leaders are aware of the importance of ‘framing to fit’ – telling the

‘innovation story’ in a way that appeals to and resonates with the values,

sentiments and goals of key audiences (Section 10.3.1).

• Ensure that participation and inclusion remain the watchwords of this

form of leadership, avoiding the natural temptation to ‘keep the cards to

the chest’ and to exclude external parties in particular from decision-

making (Section 3.2).

• Establish clinical leaders as the ‘primus inter pares’ for the innovation

initiative.

• Establish a leadership system or process that is based on professional

leadership lines.

10.6 Implications for research

In this final section we address the implications of our study for future

research, noting as a starting point that ‘the empirical literature on the

implementation of service innovations in health care is currently extremely

sparse’ (Greenhalgh et al, 2005; p.18).

1 Research is needed on the appropriate balance between centrally-

generated innovations and those that are generated locally and

disseminated laterally. The intended shift in the policy environment from

the former to the latter will provide an interesting natural experiment.

Greenhalgh et al (2005; p.227) have identified a related research gap on

behalf of the SDO programme, namely: ‘What are the harmful effects of

an external ‘push’ (such as a policy directive or incentive) for a particular

innovation when the system is not ready? What are the characteristics of

external pushes that tend to be more successful in promoting the

assimilation and implementation of innovations by health service

organisations?’

2 Work is needed to help develop and evaluate the concept and use of

‘design principles’ in facilitating successful innovation. For example,

within the new NHS policy context it might be possible to work with SHAs

(perhaps using an action research or formative evaluation design) to

explore the place of design principles for organisational innovation at the

local level.



3 The nature and place of positive organisational scholarship (see Section

10.3.2 on ‘rules-based system’) should be explored as a means of

fostering a more receptive environment for organisational innovation.

4 We need to understand more about how middle managers, such as the

managers of the TCs and front-line NHS staff in general – given their

central role in innovation – make sense of and therefore contribute to

change outcomes in different change contexts. This recommendation

builds on the conclusions of Balogun and Johnson (2005). Relatedly,

more work is needed to understand how the inevitable contests of

meaning in multi-level and multidisciplinary organisations can be more

successfully reconciled.

5 What are the sources of evidence that decision makers draw upon when

making the decision to innovate, and how are these played out in the

negotiations and debates that precede the decision and subsequently

shape its journey? In particular, how do political and power relations and

organisational roles impact on this process? This question resonates with

the conclusions of a recent study funded by the NHS South East Research

and Development Division, exploring the use of knowledge sources by

communities of practice formulating care packages for the elderly

(Gabbay et al, 2003).

6 A study is needed to explore the barriers and opportunities for change

based on the findings of theoretical planning exercises and operational

research studies. In particular what might better facilitate the influence

of such evidence on service delivery and organisation within the NHS?

Related to this, a study is needed that explores the ways in which

modellers and operational researchers might dispel the ‘Cassandra

complex’ that currently affects much of their work. Of relevance to both

of these questions is the work of MASHNET – the Network in Healthcare

Modelling and Simulation (see www.mashnet.org) – funded by the

Engineering and Physical Sciences Research Council. The results of an

SDO-funded project looking at how operational research can facilitate the

implementation of stepped care for common mental health problems is

also of interest (see SDO/109/2005 at www.sdo.lshtm.ac.uk).

7 A highly relevant methodological question, which we have struggled with

in a number of other organisational studies in the NHS, is how

researchers can best handle the problem of studying an organisational

entity that is subject to a range of (sometimes incompatible) meanings

held by key players. This problem is heightened when the research

sponsors subscribe to just one of those conflicting perceptions or expect

researchers to measure success against targets and criteria defined by

policymakers but which are being imperceptibly, perhaps deceptively,

transformed by front line managers and staff. This question arose from

Pope, Le May and Gabbay (2006). See Appendix 9 for more details of this

paper.



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Appendices

Appendix 1 Information sheet for participants

INFORMATION SHEET

Research study – Treatment Centres

University College London and University of Southampton

More than fifty NHS and Treatment Centres (TCs) will be established within the NHS

over the next five years. The Centres are a new, innovative way of providing health care

to thousands of patients who need specific diagnostic services and/or treatment (for

example, those requiring hip or knee replacements or those with cataracts). The Centres

are being specifically designed to ensure that such patients will be seen with minimum

delay and avoid long in-patient hospital stays.

This independent, three year research evaluation of TCs is funded by the NHS Service

Delivery and Organisation (SDO) Research & Development programme. The research

will be undertaken by a team led by Professor Paul Bate from University College

London’s Medical School in collaboration with colleagues at the Clinical Operational

Research Unit and the University of Southampton. This research – guided by an

advisory group that will include patient representatives as well as clinicians and

managers – will examine whether TCs are successful in increasing the numbers of

patients who are diagnosed and treated within their local health communities. The

research will also explore the ways in which some of these Centres (opening in 2002/03)

are organised and managed with the aim of learning important lessons that can then be

shared with other Centres which are due to open later (in 2004/05).

Purpose of the study

The purpose of this research project is to describe and evaluate a small sample of NHS TCs,

following them through from their initial conception and development to full implementation.

This process will entail not only the generation of findings but also the regular sharing and

validation of these findings with participants. This study will examine the process of change

as well as the impact of TCs on the organisation of patient care. An integral part of this

process will be feedback of the emerging findings to those involved – including users as well

as clinicians, managers and policymakers – which will allow the findings to be jointly

analysed. This approach will aim to ensure that the lessons will be rolled out as the rest of the

NHS adopts this model of service provision.



Methods and Procedures

Use of mathematical modelling to calculate how many and which patients will be treated, and

how best to organise services

Face to face interviews with health care staff and patients to find out how they view various

aspects of the operation and degree of success of the TCs over the three year period

Observation of health care processes in the centres

Postal questionnaires sent to health care staff to further explore how the TCs are being

organised and managed.

Topics of research interest

Reviews of the change management and innovation literatures and previous research by the

study team have identified a number of critical success factors relating to initiatives like the

development of TCs. Our interview topic guides will therefore be structured around the

following themes: organisation structure; mission and strategy; skills and development;

quality and governance issues; human resource aspects; information systems; communication;

change models; measurement; motivation, commitment and reward, teams and team working;

leadership and decision making; changes in cultural norms; changes in working practices and

patterns; relationship with key constituents; and identity, values, ethos, ideology and

commitments.

Benefits

Benefits to participating sites – and to the NHS TC programme – in general include:

An in-depth description and analysis of the design, introduction and implementation of seven

NHS TCs

An ongoing feedback process, ensuring that lessons learned from the seven case study sites

will help to improve services in the remaining TCs

As well as sharing findings among managers and clinicians in NHS TCs, the final results will

be shared widely with policymakers in the NHS, as well as disseminated in peer reviewed

(academic) journals

Innovative methods of practice fed directly into the NHS.

Potential risks and safeguards

The research team are aware of the sensitivities and ethics of researching in health care

settings and have extensive fieldwork experience in this area. They also have experience of

‘naturalistic’, unobtrusive research designed to minimise any disruption to staff or patients.

Verbal consent will be sought for all face to face interviews and for observation of any

meetings and day-to-day activities in the TCs. The team will reiterate all potential

interviewee’s rights to:

Withdraw from the project at any time

Stipulate for the removal of material from any transcripts that they believe is of a sensitive

nature

Withhold information.



Because of unfamiliarity with the intricacies of the case study sites the research team ask that

a ‘link person’ (‘Site Captain’ or ‘Gatekeeper’) be assigned to advise on – and guide – entry

into the organisation and provide any relevant background information.

Confidentiality

Involvement in this research project is entirely voluntary and assurances will be given to

participants that all discussions and interviews are entirely confidential. All interviews and

fieldnotes will be coded and stored in a locked filing cabinet. Prior permission will be sought

– where appropriate – from the organisation for any tape-recording (interviews or meetings)

or photography undertaken as part of the study. It is intended that anonymous abstracts from

the interviews may be used in publications arising from this research but any materials will

not be used without the full permission of participants. The study team will ensure that it

adheres to the ‘Research Governance Framework.

Withdrawal and Rights of Research Subjects

Participants (organisation or individual) may withdraw from the study at any time without

prejudice or penalty.

Contact details for research team

Project lead: Professor Paul Bate, Chair of Health Services Management, CHIME, University

College London, London, N19 3UA; Email: [email protected], tel: +44 (0) 20 7380

9890.



Appendix 2 Interview sampling grids for phase 1 and 2

Phase 1: inside TC

A B C D E F G H

Project ‘originators’ and site mgrs

Senior mgr resp for TC

Business/ops mgr (day-to-day)

Clinical lead

Nursing lead

Therapies lead

IS manager

Training and education

Facilities manager

Modernisation lead

Booking/scheduling

PALS/patient surveys and satisfaction

Theatres

Other clinicians

Nursing staff

Other



Phase 1 and 2 trust level/host(s)

A B C D E F G H

Exec resp for TC/surgery

Chief executive

Human resources director

Director of finance

Director of nursing

Director of strategy/development

Medical director (surgery)

Capital projects/estates

Head modernisation team

Other

Booking/ scheduling

PALS/patient surveys and satisfaction

Theatres

Other clinicians

Nursing staff

Other



Phase 1 and 2: meetings A B C D E F G H

Project co-ordination

Management board

Medical board

Modernisation board

Clinical governance board

Internal TC team meetings

Phase 2 external stakeholders

A B C D E F G H

PCT

Strategic health authorities

Patient groups/patient involvement (lead for TC)

Workforce confederation

Trade unions

Neighbouring trusts

Other



Appendix 3 Literature review search methods

Issues related to the literature searching

The literature search was undertaken with the aid of Alison Price, Information

Officer at the Wessex Institute for Health R&D (WIHRD), University of

Southampton. At the outset, it was clear that there were at least four factors

which rendered a sharply focused ‘systematic review’ in the narrow sense

inappropriate and, indeed impossible.

• There was no single research question or clearly specified outcome

measure.

• The questions that were being asked were not, for the most part, ones

for which categorising and subsequent selection of retrieved literature in

terms of a methodological hierarchy was appropriate. Opinion

statements, policy documents etc were all potentially relevant. Thus

selection criteria have been largely ones of content and topic, rather than

methodological quality, although comments are made when relevant

about the possible status of any research evidence. Synthesis has been a

qualitative rather than quantitative process.

• The brief was mainly to identify literature on treatment centres as a

health care policy development, and an organisational innovation. Some

key refereed journals, and most of the non-research literature are not

included in Medline for this area. Alternative searching was undertaken,

but the extent of this was limited within the time constraints. Extensive

manual entry of retrieved literature into a project bibliographic database

was required.

• The terms ‘treatment centre’ and ‘diagnostic and treatment centre’ are

not well-established keywords in relevant databases. Free text searching

for these exact terms (or similar ones) produces thousands of hits

covering almost every kind of health care provider and more. (Some UK

‘treatment centres’ are penal reform institutions, and the abbreviation

‘DTC’ also stands for ‘direct to customer’ in advertising and sale of

pharmaceutical products). Searching under ‘ambulatory care centre/er’

generates much relevant literature, but also articles about US facilities

more akin to NHS ‘walk-in’ primary care centres, chronic illness care

services etc.

Searches undertaken

Electronic databases and journals

Essentially the strategy was to search databases including material on health

care organisation, or limiting Medline searches to this area, under the

following terms ‘treatment cent$’, ‘day surgery’, ‘surg$ cent$’, and ‘elective

surgery’, dating from 1984 or the start of the relevant database if later. Only

English language material was included and, for Medline, the search was

confined to UK, US, Canada and Sweden.



In addition to the well-established databases serving the health services

research community, databases with fuller coverage of social science and

policy literature (SSCI, Econlit and EBSCO Business Source Premier) were

also searched. A number of key UK and US health care journals were

searched (online contents) for specific articles on treatment/surgical centres

and for generally relevant articles, for example on hospital restructuring as

this emerged as an important aspect of the general policy background.

Websites

The Department of Health’s website was searched on ‘treatment centres’ on

several occasions (because of the reconstruction of the site concurrent with

the literature search), with appropriate links being followed up, in particular

the Modernisation Agency’s website. The website for the Royal College of

Surgeons (England) was also scanned.

A number of web searches using the Google crawler engine were conducted

for example using ‘treatment centres’ and ‘ACAD Central Middlesex Hospital

Trust’ and ‘NHS Elect’ as exact terms. As is generally found in such searches,

many hits were found, many of which were duplicates of documents already

found (or of little relevance or questionable quality). However, this was the

main source for information from local NHS organisations.

‘Grey’ and background literature and personal contacts

Google and other online searches generated much ephemeral and

unpublished literature, including a number of documents produced by NHS

authorities and trusts relating to service development (although the extent to

which NHS institutions make such documents publicly available online is very

variable).

Other research teams

In the course of searching, and from background knowledge, two relevant

research teams were identified. A study, from an organisational theory

perspective, of the development of an innovatory Ambulatory Care and

Diagnostic Centre has been undertaken by current and ex-members of the

School of Management at Royal Holloway, University of London, led by

Professor Charles Harvey, now at the University of the West of England. Five

published papers, none of which were identified by the database searches,

have been obtained from this team. Please note that the archive relating to

the research work on the development of the relevant NHS hospital trust in

the 1990s is not currently in the public domain. Professor Charles Harvey

would be happy to answer specific queries ([email protected]).

Chris Howorth, Lecturer in Management at Royal Holloway, is working on a

PhD on this material ([email protected]).

The second team, led by Professor JA Bowers and Ms G Mould of the

Department of Management and Organisation, University of Stirling, has been

examining the organisational impact of introducing ambulatory care facilities

(and subsequently treatment centres), mainly through simulation exercises.

This team has supplied copies of one published and one draft article, a final

report for the chief scientist at the Scottish Health Department and details of

forthcoming papers. Website material has also been downloaded. For further



information see

www.stir.ac.uk/departments/management&organisation/research or email

[email protected]

Background literature

In addition to specific searches, some analysis was undertaken of more

general background health services research and policy literature. For

example, some publications on wider aspects of NHS health care policy

developments, and health services research related to organisational change

and quality improvement initiatives etc are referred to in the report. This was

done to help contextualise the TC initiative, particularly because of the very

limited research literature found specifically on the development of TCs or on

what has been suggested as the closest US equivalent, surgical centers. That

there is little literature on TCs as such, in England to date, is not surprising,

given that they have been implemented recently. However ambulatory

surgical centers or similar have existed in the US for more than two decades.

Yet, scarcely any general articles about the history or impact of this specific

form of health care organisation were identified in mainstream health policy

journals. Reference to ambulatory surgical centers or equivalent is absent or,

at most, only made in passing, in a number of well regarded general articles

and books on recent developments in the US health care system (for example

Peterson, 1998; Scott et al, 2000; Shortell et al, 2000). While this absence of

discussion and analysis may reflect problems with the searching, it might also

indicate some of the following possibilities:

• that ambulatory surgical centers have become such a taken-for-granted

‘sector recipe’ in US health care that they now arouse little policy or

research controversy

• that, although growing, the ambulatory surgical sector is still too small to

be a major focus of interest

• that the surgical center as such is not a significant organisational form

within the dominant conceptual frameworks employed to analyse US

health care system developments. For example, while most (but not all)

surgical centers are ‘for-profit’ organisations, they are only one form of

this type of provider, the expansion of which is a major theme of US

health policy analysis. Similarly, they may be seen as only one of many

developments of the general process of hospital reconfiguration and

‘downsizing’ that forms the second main theme of current macro-level US

health policy analysis.

As a check for other general literature on ambulatory surgical centers a

request was posted on the MEDSOC email list (maintained at Brown

University). This is a very active list serving mainly the medical sociology

section of the American Sociological Association. Immediately prior to this

posting, there had been several threads concerning literature on health care

organisation topics. That only two replies were received may indicate that

ambulatory surgical centers are not in themselves a current topic for active,

critical social science research at present. Of the two replies, one suggested

the website for the Medicare Payment Advisory Committee (MedPAC), an

independent federal body established in 1997 ‘to advise the US Congress on

issues affecting the Medicare program’. MedPAC issues reports with

recommendations relating to Medicare payments, in March and June each



year and holds public hearings. The March 2004 report contains much useful

factual information about Medicare funded ASC services and was downloaded

(MedPAC, 2004). Previous reports and hearings might also be informative but

have not been consulted in the time available. The second response

suggested parallels between NHS treatment centres and US free-standing

abortion clinics. This highlights the ambiguity of the term ‘elective’, but also

points to longstanding contractual relationships between the NHS and the

private and voluntary sector in this highly focused area of service provision

which may be a model for TCs.

Summary observations on the literature searching

Approximately 400 items were entered into an Endnote ‘library’ for the

project. Few of the retrieved items deemed directly relevant to TCs per se are

research articles in peer-reviewed journals. A decision was taken to

concentrate on the greyer, policy orientated literature in order to produce a

narrative about the development of TCs. Selection criterion was essentially

perceived relevance to the topic and inclusive of a wide range of sources. In

terms of established information databases, HMIC was probably the single

most useful source in that almost all retrievals were useful, and many were

not found through PubMed. It should be noted that much of the material

included emanates from government departments and agencies, and needs to

be interpreted accordingly. Gaps in the review include a lack of material on

the commissioning side (PCTs and GPs) or patients’ views as these do not

appear prominently in the literature as searched. Similarly, there is little on

nurses, although some attempt was made to search the nursing literature.



MAIN SEARCH STRATEGIES AND RESULTS

Examples of the search strategies adopted at the beginning of the project are

given below. These are followed by tables giving the results of the initial

searches. Except where indicated these tables do not include all items added

to the bibliographic database during the review.

Table A1 Search 1

Date searched 04/05/04 Database: Ovid MEDLINE(R) <1966 to April Week 3 2004>

Search Strategy:

1 ambulatory care cent$.mp. (167)

2 Ambulatory Care/ (24548)

3 exp Ambulatory Surgical Procedures/ (6725)

4 day surgery.mp. (3414)

5 (diagnos$ adj3 treatment cent$).mp. [mp=title, original title, abstract, name of substance,

mesh subject heading] (131)

6 treatment cent$.mp. (3125)

7 (treatment adj2 (centre$ or center$)).mp. (3626)

8 independent treatment cent$.mp. (2)

9 elective care.mp. (11)

10 elective surgery.mp. (3581)

11 exp Surgical Procedures, Elective/ (2977)

12 dedicated unit$.mp. (47)

13 surgicent$.mp. (1123)

14 (ambulatory care adj3 diagnos$ cent$).mp. (1)

15 Outpatient Clinics, Hospital/ (10515)

16 1 or 5 or 8 or 12 or 14 (348)

17 2 or 3 or 4 or 9 or 10 or 11 or 13 or 15 (49338)

18 6 or 7 (4546)

19 hi.fs. (184640)

20 og.fs. (201339)

21 or/19-20 (383092)

22 17 and 19 (248)

23 18 and 19 (44)

24 [from 5 keep 3-4,13-14,51,74,77,82,102,104,107,111,114,121,127,130] (0)

25 (diagnos$ adj2 (treatment adj2 (centre$ or center$))).mp. (141)

26 *’Ambulatory Care Facilities’/ (3370)

27 16 (348)

28 limit 27 to (english language and yr=1984-2004) (261)



(Table A1 continued)

29 [from 28 keep 4,8-10,19,21,24-25,36,52,54,56,70-72,78,82,85-86,89-90,92-93,101-

102,104-105,113-114,116-117,122,125,130,136,142,144,146,150,156,161,164-

165,171,181-183,185-186,188-189,192,198,200-204,206,210,212-215,218-221,225-

227,229-235,238,240,242-246,248-259] (0)

30 17 and 21 (5347)

31 7 and 20 (230)

32 31 not 29 (230)

33 [from 32 keep 1,11-13,19,62-63,73,92-93,100-101,117,120-121,135,138-

139,144,147,160,165,169,172,185-188,195,221] (0)

34 26 and 20 (1158)

35 34 and ut.fs. (100)


37 [from 36 keep 2,11,16,20,29,42,46,49,68,76-77] (0)

38 surg$ cent$.mp. (1488)

39 13 or 38 (2363)

40 39 and 10 (10)

41 *’Surgicenters’/ (820)

42 from 40 keep 1,5,7-8,10 (5)

43 exp Surgicenters/og, ec, es, hi, td [Organization & Administration, Economics, Ethics, History,

Trends] (608)

44 from 43 keep 4,11,19,23-24,34,41,72,110-111 (10)

45 from 43 keep 110-111 (2)

46 exp Surgicenters/og (391)

47 Evaluation Studies/ (114779)

48 46 and 47 (4)

49 from 48 keep 1-4 (4)

50 47 and 38 (19)

51 from 50 keep 4,6-7,13,17 (5)

52 from 51 keep 1 (1)

53 1 or 5 or 6 or 7 or 8 or 13 or 14 or 38 or 41 or 43 (7051)

54 3 or 4 (9343)

55 10 or 11 (6003) Total intervention Set A

56 53 and 55 (25)

57 imit 56 to (english language and yr=1984-2004) (21)

58 exp Emergency Medical Services/ (48297)

59 exp Emergency Service, Hospital/ (22023)

60 58 or 59 (48297)

61 53 not 60 (6893)

62 from 57 keep 1-21 (21)

63 2 or 3 or 53 (37592) Total population Set B

64 63 and 55 (142)




65 limit 64 to (english language and yr=1984-2004) (129) Final elective surgery issues

66 from 65 keep 2,4-7,9-10,13,18,21-22,24-25,27-28,30-42,44-50,52-56,58-60,63-70,72-

77,79-80,83-84,91-92,94-96,98,101-102,106-109,111,113,115,120-123,125-126,129 (83)

Download file

Table A2 Search 2

Database: EMBASE <1980 to 2004 Week 18> Search Strategy:



3 exp Ambulatory Surgical Procedures/ (3130)


5 (diagnos$ adj3 treatment cent$).mp. [mp=title, abstract, subject headings, drug trade name,

original title, device manufacturer, drug manufacturer name] (104)






11 exp Surgical Procedures, Elective/ (5441)




15 Outpatient Clinics, Hospital/ (4520)

16 1 or 5 or 8 or 12 or 14 (222)

17 2 or 3 or 4 or 9 or 10 or 11 or 13 or 15 (21410)

18 6 or 7 (3970)

19 hi.fs. (0)

20 og.fs. (0)

21 or/19-20 (0)

22 17 and 19 (0)

23 18 and 19 (0)

24 [from 5 keep 3-4,13-14,51,74,77,82,102,104,107,111,114,121,127,130] (0)


26 *’Ambulatory Care Facilities’/ (812)

27 16 (222)


29 [from 28 keep 4,8-10,19,21,24-25,36,52,54,56,70-72,78,82,85-86,89-90,92-93,101-

102,104-105,113-114,116-117,122,125,130,136,142,144,146,150,156,161,164-

165,171,181-183,185-186,188-189,192,198,200-204,206,210,212-215,218-221,225-

227,229-235,238,240,242-246,248-259] (0)

30 17 and 21 (0)




31 7 and 20 (0)

32 31 not 29 (0)

33 [from 32 keep 1,11-13,19,62-63,73,92-93,100-101,117,120-121,135,138-

139,144,147,160,165,169,172,185-188,195,221] (0)

34 26 and 20 (0)

35 34 and ut.fs. (0)


37 [from 36 keep 2,11,16,20,29,42,46,49,68,76-77] (0)


39 13 or 38 (1114)

40 39 and 10 (20)

41 *’Surgicenters’/ (812)

42 from 40 keep 1,5,7-8,10 (5)

43 [exp Surgicenters/og, ec, es, hi, td [Organization & Administration, Economics, Ethics, History,

Trends]] (0)

44 [from 43 keep 4,11,19,23-24,34,41,72,110-111] (0)

45 [from 43 keep 110-111] (0)

46 [exp Surgicenters/og] (0)

47 Evaluation Studies/ (23960)

48 46 and 47 (0)

49 [from 48 keep 1-4] (0)

50 47 and 38 (14)

51 [from 50 keep 4,6-7,13,17] (0)

52 [from 51 keep 1] (0)


54 3 or 4 (5486)

55 10 or 11 (7400)

56 53 and 55 (23)


58 exp Emergency Medical Services/ (7261)

59 exp Emergency Service, Hospital/ (7261)

60 58 or 59 (7261)

61 53 not 60 (5937)

62 [from 57 keep 1-21] (0)

63 2 or 3 or 53 (13197)

64 63 and 55 (133)


66 [from 65 keep 2,4-7,9-10,13,18,21-22,24-25,27-28,30-42,44-50,52-56,58-60,63-70,72-

77,79-80,83-84,91-92,94-96,98,101-102,106-109,111,113,115,120-123,125-126,129] (0)

67 from 65 keep 7-8,10-11,13-16,18-31,34,37-39,41,44-48,50-59,61-63,65,67-70,72-74,77,79-

86,88-93,95-96,98,100,103-105,108-110,112-113,115-116 (82) Download file



Table A3 Search 3

Database: HMIC Health Management Information Consortium <May 2004 Search Strategy:




4 (diagnos$ adj3 treatment cent$).mp. [mp=title, other title, abstract, heading words] (34)












16 3 or 8 or 9 (622)

17 15 and 16 (28)

18 limit 17 to yr=1984-2004 (28)

19 from 18 keep 1-28 (28) Download file

Table A4 Search 4

BNI Database: British Nursing Index (BNI) <1985 to March 2004> Search Strategy:




4 (diagnos$ adj3 treatment cent$).mp. [mp=heading words, title] (3)













14 or/1-13 (622)

15 14 not (3 or 9) (39)

16 limit 15 to yr=1984-2005 (39)

17 16 not (5 or 6) (6)

18 [from 17 keep 7] (0)

19 1 or 4 or 5 or 6 or 11 or 12 or 13 (42)

20 19 not (5 or 6) (7)

21 [from 20 keep 2-11,14-16,18,21-22] (0)

22 treatment centre$.mp. (22)

23 diagnostic & treatment centre$.mp. (1)

24 ACAD.mp. (0)

25 exp AMBULATORY CARE/ (0)

26 or/22-25 (22)

27 (diagnostic and treatment centre$).mp. [mp=heading words, title] (1)

28 (or/26) or 27 (22)

29 investment.mp. and reform for NHS hospitals.ti. [mp=heading words, title] (0)

30 ‘REFORM’/ (0)

31 ‘NHS PLAN’/ (0)

32 26 and (30 or 31) (0)

33 [from 32 keep 1,3-6] (0)

34 28 and 31 (0)

35 34 not 33 (0)

36 28 and 30 (0)

37 surgicent$.tw. (2)

38 [from 21 keep 1-10] (0)

39 [from 21 keep 1-10] (0)

40 4 or 13 or 23 or 27 (3)

41 40 not (33 or 21) (3)

42 from 41 keep 1 (1)

43 [from 41 keep 1,3-17,19-30] (0)

44 from 4 keep 1-3 (3)

45 4 or 13 or 23 or 27 or 37 (5)

46 45 not 44 (2)

from 46 keep 1 (1)



Table A5 Search 5

CINAHL Database: CINAHL <1982 to April Week 1 2004> Search Strategy:-




4 (diagnos$ adj3 treatment cent$).mp. [mp=title, cinahl subject headings, abstract,

instrumentation] (21)










14 or/1-13 (4186)

15 14 not (3 or 9) (3373)

16 limit 15 to yr=1984-2005 (3281)

17 16 not (5 or 6) (2796)

18 from 17 keep 7 (1)

19 1 or 4 or 5 or 6 or 11 or 12 or 13 (1320)

20 19 not (5 or 6) (829)

21 from 20 keep 2-11,14-16,18,21-22 (16)

22 treatment centre$.mp. (94)

23 diagnostic & treatment centre$.mp. (4)

24 ACAD.mp. (92)

25 exp AMBULATORY CARE/ (2179)

26 or/22-25 (2363)

27 (diagnostic and treatment centre$).mp. [mp=title, cinahl subject headings, abstract,


28 (or/26) or 27 (2363)

29 investment.mp. and reform for NHS hospitals.ti. [mp=title, cinahl subject headings, abstract,


30 ‘REFORM’/ (0)

31 ‘NHS PLAN’/ (0)

32 26 and (30 or 31) (0)

33 [from 32 keep 1,3-6] (0)

34 28 and 31 (0)




35 34 not 33 (0)

36 28 and 30 (0)

37 surgicent$.tw. (14)

38 from 21 keep 1-10 (10)

39 from 21 keep 1-10 (10)

40 4 or 13 or 23 or 27 (25)

41 40 not (33 or 21) (25)

42 from 41 keep 1 (1)

43 [from 41 keep 1,3-17,19-30] (0)

44 from 4 keep 1-3 (3)

45 4 or 13 or 23 or 27 or 37 (39)

46 45 not 44 (36)

47 from 46 keep 1 (1)

48 1 or 4 or 12 or 13 or 23 or 27 or 37 (78)

49 limit 48 to (english and yr=1984-2004) (73)

50 from 49 keep 4,6,9-10,19-22,35,40,48-49,57,66,70,72 (16)



Table A6 Record sheet of initial WIHRD searches

Databases

Years searched

Date of search and strategy saved name

Number of hits (download file)

Number of items retained in database after scrutiny and elimination duplicates

Medline

1966-March

week 3 2004

31/03/04

182 137

Medline 1966 to

April Week 3

2004>

04/05/04

med-elective2

83 32

Embase

1984-2004

Week 14

05/04/04 34 12

EMBASE <1980

to 2004 Week

18>

05/04/04

emb-elective

82 25

PubMed (limit

to last 90

Days)

23/04/04 1 1

HMIC 06/04/04 28 22

CINAHL 06/04/04 16 12

SCI/SSCI 21/04/04 7 7

BNI 06/04/04 5 5

ASSIA 06/04/04 7 5

NHS-CRD 21/04/04 0

EconLit 84-04

(( surg* cent*

)or( treatment

cent* )or(

surgicent* ))

and (PY:ECON

=

1984-2004)

30/04/04

10 10

Health Affairs

Journal

Surg* cent* 19 19

Total references 474 287



Table A7 Initial searches undertaken by MAE: April-June 2004

Database or source

Years searched

Search strategy/date

Number of hits: initial searches

New references added to database

King’s Fund information

service: 1984-March

2004

surg* cent* OR elective

surg* OR day surg* OR

ambulatory care

73 33

Business Source Premier

1984-May 2004

(surg* cent*) 77 14

Jnl of Health Services

Research & Policy:

1999-2004

Scanned for relevant

papers (including

general background)

6 4

Milbank Quarterly:

1994-2004


papers (including

general background)

8 8

Jnl of Health Policy,

Politics & Law:1994-

2004


papers (including

general background)

3 3

British Medical Journal:

1995-2004

(in addition to Medline

search)

Health care organisation

collection scanned for

background

15 10

Managed Care surg* cent* 24 6

Royal College of

Surgeons website

Day Surgery OR

Treatment Centres

6 3

Department of Health

(incl. modernisation

agency) website

Treatment Centres

Ongoing throughout

n/a 19

Health Service Journal Ongoing hand search

April 2004-Sept 2005

n/a 24

Google Searches

10/03/04 & 11/05/04

ACAD Central Middlesex

Hospital Trust

First 100 of 1200 hits

scanned

11



Appendix 4 Interview topic guides

Organisationally focused interviews: semi-structured, tape-recorded

Who: Key stakeholders within /outside the organisation

Aim: develop understanding(s) of the interpretations associated with TCs and

how these change and develop over time; understand and clarify the

meanings people attach to:

• TCs – early and altering views, speculations and understandings (for

example physical/virtual). How will things change over next year (and

why?).

• Patients – how ways of working with patients differs from ‘traditional’;

how does the patient/carer ‘experience’ TC; assessment/evaluation of

practice (formal and informal QA); degree of commitment to new

working (cut across professional groups involved in delivering service).

• Wider organisation(s) – relationships and how these are maintained (or

not); formal and informal structures.

• Each other – difficult/easy to adopt new philosophy/approaches; new

behaviours and attitudes, quality of relationships, morale, enthusiasm

and commitment.

• Their job/experience; role (extended/expanded), tasks, work patterns,

compared to other work experiences, aspirations, motivation and

rewards.

• The wider learning partnership – TC networks, MA, other support groups/

networks.

Key areas for interviews (note: questions can be ‘grounded’ in critical

incidents and real-life experiences and events of both patients and staff).

• identity, values, ethos, ideology and commitments (personal/cultural)

• relationship with key constituents

• mission and strategy (type/how formed; operationalised as

policy/monitored)

• change model/underlying theory of change

• establishing existing/new/altered changes in practices (for example

service redesign activities)

• changes in cultural norms/rules

• leadership and decision making – who and how it is exercised

• teams and team working; group dynamics – within and between teams

(in/out of TC)

• motivation, commitment and reward

• organisational structure and structuring

• performance measurement and management

• quality and governance issues

• skills, training and development

• politics and political processes



• HR aspects (including stress)

• IS/IT aspects

• information and communication.

Prompts

• Role and career history – talk through a role map and key relationships.

• When did you first hear of TCs / this TC; how did you come to be

involved?

• What were your initial perceptions/expectations/anxieties) – and now?

• What have been the main shaping factors in this TC’s development

(phases/events)

• Can you recall the main challenges early on; what was your response to

these?

• So how are things going now? (highlight high and low spots – and any

related actions)

• What are the priorities/your predictions for the immediate future?

• External:

- is there central policy support for rationale / underlying principles?

- divergent perspectives and aspirations between actors and

stakeholders

- short-term operational targets vs longer-term ‘vision’ espoused by TCs

- understanding/co-operation between local trusts and PCTs

- impact on other trusts waiting lists and activity targets

- existing commissioning arrangements hinder or support the operation

of TCs

- local politics

• Host organisation:

- what was it like before the TC?

- what are the ‘politics’ associated with the implementation

- what are your views on the development and organisation of the TC?

- does the organisational structure facilitate or impede TC development?

- infra-structural support (for example IT, equipment, training)?

- is the TC perceived as/treated as, a ‘closed’ system by the wider

organisation?

• The TC itself:

- what is the underlying philosophy of the TC?

- who was involved in developing this philosophy?

- how easy / difficult has it been to implement this philosophy?

- staff involvement in development and operationalisation of this

philosophy?

- how has the developmental process and any other change processes

been led?

- does the physical environment match the aims and rationale of the TC?

- are the staff excited (and motivated) by the novel approach of the TC?

- skill mix/workforce planning adequately and imaginatively addressed?

- communication, information management/scheduling systems –

sufficient?

- how were the ICPs agreed, implemented and monitored?



- how is the interface with PC, intermediate care and social services

managed?

- what challenges currently face the TC and how are they being

addressed?

- interact/influence other TCs?

- what lessons has this TC learnt from others?

- how have lessons learnt in this TC been communicated to others?

- how does the TC interact with the Modernisation Agency- influence?

Also probe:

• IT

• knowledge management

• HR in relation to workforce planning and training and development

• clinical governance

• the processes through which ‘evidence’ and ‘experts’ contribute to

redesign

• the politics of change

• cultural change

• the overall management of the change management process itself.

Documentary data collection

Where possible obtain copies of relevant documents for example:

• business plans

• design brief/ drawings

• minutes from internal TC team meeting, boards

• protocols and guidelines; care pathways

• key sources of information such as guidance for clinicians,

• information sheets and booklets provided to patients and their carers

• publicity materials.



Appendix 5 Results of CHIME survey of treatment centres

Type of TC TC

branding

Example of

modernisation

Difference in

productivity

Expectations

met

Impact on

waiting

times

Incentivisation Operational

challenges

now

Lessons for

new TCs

A PCT,

consultant-led,

multi-specialty,

add on to

existing

community

hospital, day

case only

Yes – as a

diagnostic

and

treatment

centre

Nurse-led

endoscopy

service, looking

at more nurse-

led initiatives

Yes due to extra

theatre, surgical

staff and services

rather than

modernisation.

Too early to say

what impact of

modernisation will

be

Definitely Certainly

lighter;

always been

quite short

anyway,

some

improvement

though

No. Existing

contract,

sessional

payment

Looking at

how we

manage

capacity in

the future

More realistic

timescales

Clinical

involvement

from day one

Reviewing skill

mix

Budget for

upgrading

equipment

B Virtual – 3

distinct areas,

single specialty

Yes Supported

discharge team

(multi-

disciplinary)

We have tried to

modernise what

we do, with that

we have improved

productivity and

the capacity is

greater than it

was. With

modernisation

does come greater

productivity

Not overall.

Still dealing

with long

waiters who

are complex

cases. In a

better

position than

this time last

year but still

struggling to

meet the 12

month target

No Patient and

staff

expectations

(e.g. 23 hour

stay);

cultural

challenges

that come

with new

extended

roles

Abbreviations: LOS = length of stay; GPSI = general practitioners with special interests; LPC = London Patient Choice



Type of TC TC

branding

Example of

modernisation

Difference in

productivity

Expectations

met

Impact on

waiting

times


challenges

now

Lessons for

new TCs

C Cataracts and

orthopaedics

Yes – as a

diagnosis

and

treatment

centre

Pre-

assessment;

Scheduling

Group (learnt

from US); new

staff (especially

nursing roles);

hip and knee

club and patient

interaction

Increase in

productivity (LOS

down from 9+

days to 5-7 days

for hips and

knees) because of

additional

surgeons/

theatres; pre-

assessment

possible because it

is elective surgery

only

Cataracts:

down from

12 months to

3 weeks but

now demand

not there so

reducing

sessions

No (but some

reimbursement

for extra travel)

Excess

capacity: lack

of demand

and IS TC on

the way.

Funding

implications.

Uncertainty

re impact of

Patient Choice

from next

year, trusts

only referring

long-waiters

Instrumentation

Financial flows

PCT

engagement

Scheduling

group

D Virtual – 5

distinct areas

Yes – as a

TC (but

difficult as

virtual)

Urology: one

stop

haematuria

clinic, nurse-led

cystoscopy

Orthopaedics:

joint

assessment

team, patient

education

Urology: yes.

Orthopaedics: in

its infancy

P: yes, in terms

of plans

C: no – looking

for better

structure to be

in place. Hasn’t

gone far enough

Haven’t had to

yet; not saying

we won’t but not

yet

Buy-in from

clinicians;

Foundation

status (more

change)

Get clinical staff

on board; have

vision and

understand it

extremely well;

sell it to

clinicians like

you’ve never

sold before

Strict project

management

Do eligibility

criteria and

patient journey

as early as you

can



Type of TC TC

branding

Example of

modernisation

Difference in

productivity

Expectations

met

Impact on

waiting

times


challenges

now

Lessons for

new TCs

E LPC Yes – as a

diagnosis

and

treatment

centre at

moment but

will be as a

TC

No innovation

around staffing,

recruitment and

process,

theatres the

same. P: 'run

along totally

traditional

lines', 'staffed

in a traditional

way'

LOS the same Not met

business plan;

not met income

targets

Helped to

achieve it;

avoided

breaches and

that’s the

whole

function

really

Going to pay

medical staff for

the work done

as opposed to as

an extra bonus if

they do extra

work. They get

paid per item as

opposed to per

day or per half

day

C:

Infrastructure

not in place;

maintaining

relationships

to keep work

coming in

P: filling

capacity,

justifying

activity and

income;

coming up

with firm

strategy and

timescale

C: Know how

much funding

you have

P: think about

admission

processes very

carefully;

matching staff

skillmix to

patient demand

F Virtual,

cataract

(purpose built

ophthalmic

suite) and

orthopaedics

(new theatre,

25-30 beds

combined from

existing ward

and day

surgery unit)

Orthopaedics:

cut at least one

visit, electronic

booking

system, theatre

staff trained to

advanced

health care

assistants

Promised

referrals from

neighbouring

PCTs never

materialised;

possibility that

ophthalmology

TC will have to

close when lists

get down to 3

months

9-month wait

for

orthopaedics

at moment -

longest wait

list; aiming

for 6 months

by August

2004

Ophthalmology:

consultants will

get paid per

patient with a

bonus if targets

achieved

P: we've been

carrying all the

risk 'don't lay a

brick until you

have the work

signed in blood

by the PCTs'



Type of TC TC

branding

Example of

modernisation

Difference in

productivity

Expectations

met

Impact on

waiting

times


challenges

now

Lessons for

new TCs

G C: just an

extra

orthopaedic

operating

theatre, 'it's a

waiting list

initiative not a

treatment

centre', beds

not protected

P:

ophthalmology

better fits US

surgi-center

notion

C: no,

'anyone who

opens their

mouth in

my

presence

and calls it

a TC gets

me jumping

down their

throat very

fast'

C: pre-

assessment

clinic but 'no,

because nobody

has given us

any money'

P: delayed

transfer of care,

moving

inpatient work

to day case, 23

hour facility;

cataract

pathway

C: we're more

productive than

we were a year

ago but then we

were more

productive a year

ago than we were

the year before

that. LOS will

continue to

decrease but less

potential for

theatre usage

P: LOS has come

down by 0.6 since

start of year but

massive increase

in referrals

P: no, the US

model has been

watered down

to a capital

project

programme

C: not yet,

waiting list

still a year

but operating

theatre only

been open

for about 8

weeks.

Hasn't

registered at

moment

P: cataract

waiting times

just under 6

months now,

hoping to get

it down to

just above 3

by March

2004

C: considered

certainly but

didn't have

money. Would

achieve a lot if

we could

Income

streams; in

short term,

the

expectation

of the health

economy on

what we can

put through;

in long term,

selling some

of the

capacity

C: don't start

without any

revenue;

P: get business

plan done

properly first,

have activity

signed up

before you

even start,

involve

clinicians as

early as

possible, look

to fast

turnover, high

volume, build

separately from

main hospital



Type of TC TC

branding

Example of

modernisation

Difference in

productivity

Expectations

met

Impact on

waiting

times


challenges

now

Lessons for

new TCs

H C: 'the

diagnosis and

treatment

centre that

was planned

for this trust

has not gone

ahead' but

funding for

new eye unit is

in line with

philosophy of

diagnosis and

treatment

centres.

Outpatient

ophthal.

P: no,

'although

it's called a

TC it's

actually an

extended

day unit'

C: pre-

assessment

process,

efficient use of

operating

theatres, book

directly onto

lists

C: moved from

four to six cataract

operatons per list,

30% improvement

in outpatients

P: in some areas

yes, it's quite

slow. Too early -

'if we had the staff

earlier and more

time to focus on

some of the

process mapping

re-engineering, I

think we'd have

got more of that'

C: no as don't

have single,

integrated

building and a

learning culture,

but productivity

gains

'unexpectedly

effective'

C: massively

reduced,

gone down

from about

nearly 2000

patients

waiting to

about 400 in

two years

P: improved

access for

elective

surgery,

access has

significantly

improved

C: no, haven’t

addressed but

some of

operating lists

do seem to be

worth an

incentive

scheme as

productivity is

more important

than the actual

unit staff cost

P: have done

(paid per case)

to a small extent

with additional

contracted

activity

P: converting

inpatients

into day

patients

C: reach

consensus on

productivity

expectations on

individual

operating lists

at an early

stage; don't

forget

infrastructure

to back up

broader aims of

a TC

P: get given

more time,

appoint a full

time project

office and have

different sub-

groups, have a

clinical lead

clearly

identified, do

the demand

capacity

planning early

enough, train

staff earlier



Type of TC TC

branding

Example of

modernisation

Difference in

productivity

Expectations

met

Impact on

waiting

times


challenges

now

Lessons for

new TCs

I A process not a

building'; six

projects lasting

18 months

(ophthal., day

surgery,

general

surgery,

orthopaedics)

No: closes

in

December

2003; no

longer

funded after

that

Gynae: one-

stop clinic

Not in the first

year - we were

600 cases under

our plan although

overall

productivity went

up significantly.

This year

improved

significantly.

Orthopaedics: LOS

down to 4 days for

hips and knees

Very successful

where dedicated

discrete

facilities (e.g.

ophthalmology)

; various levels

of success after

that

Will achieve

a month wait

by December

2003. Been a

major

achievement:

echo

ultrasound

waits went

from six

months to 6

weeks and

MRI from 3

months to 4

weeks.

Gynae: 80

surgical

patients

better than

expected (6

month waits)

as they so

efficient in

patient flow,

same for OP

waits

No. Considered

but dismissed.

Didn't feel could

give one group

of staff an

incentive against

another group of

staff. Just wasn't

feasible

Closing -

financial

reasons, no

money left

Project

managers need

clinical

credibility and

organisational

knowledge;

robust project

management

and good audit

trail from

outcomes and

QI and financial

flows;

timescales were

ludicrous



Type of TC TC

branding

Example of

modernisation

Difference in

productivity

Expectations

met

Impact on

waiting

times


challenges

now

Lessons for

new TCs

J Added 1

orthopaedic

theatre to 3

pre-existing;

'we were

probably

always a TC,

even before it

actually

happened'

No. Staff,

PCTs and

patients

wouldn't see

anything

different

from what

we used to

do. Starting

to go

through that

process

Developed a

health care

assistant role -

releases trained

staff to

concentrate on

other duties

TC programme has

shown we are a

little of pace in

productivity terms.

Best we've been

able to do in past

is 3 in an all-day

list but looking to

do 4 in future -

down to service

redesign, looking

at patient journey

and joining up

pieces of the

jigsaw

Surgeons paid

waiting list

initiatives,

overtime on a

cost per case

basis - helped

gee-up the

system

Can do better

re productivity

- want to

work with

clinicians to

improve

throughput/

performance

Challenge of

Patient Choice

- heard horror

stories across

the NHS that

new TCs have

been built but

no agreement

in place to

move patients

across to it

Takes longer

to achieve

than you

imagine - have

to change the

culture of the

workforce

Bricks and

mortar are

reasonably

straightforward

but persuading

people to work

differently and

to change long

established

clinical

practices is

harder

K Temporary

operating

theatre

(orthopaedics)

; (phase 2 in

2004 - new

diagnosis and

treatment

centre

building)

Yes -

keeping the

name

diagnosis

and

treatment

centre (as

doing

diagnosis as

well as

treatment)

Little or no

modernisation

or changes in

practice. Phase

2 will look at

modernisation

Greater

productivity (10-

25%) due to extra

theatre not

modernisation

Increasing

capacity by

employing extra

consultant and

having additional

operating space

Mean waiting

time is 3-4

months, was

8-9 months

No. Varied

thoughts around

that - evening

operations and

using spare

capacity for

surgeons

wanting to do

private work on

site. Haven't

discussed fee-

Looking at

opportunities

for changing

care

pathway,

getting

optometrists

involved,

doing pre-

assessment a

little earlier

Co-locate

outpatients

near theatres

and other

components of

the service



for-service at all

Type of TC TC

branding

Example of

modernisation

Difference in

productivity

Expectations

met

Impact on

waiting

times


challenges

now

Lessons for

new TCs

L PCT diagnosis

and treatment

centre

(virtual). GPSI

led diagnostic

service

Yes - will

keep

diagnosis

and

treatment

centre

identity

GPSI

developments,

nurse lead

roles, multi-

professional

approach to

service delivery

Increased

productivity

around putting

extra capacity into

the system

Little slow on

uptake but

grew as people

became aware

of services.

Created extra

capacity around

endoscopy and

vascular

assessment,

made services

more accessible

(pre-operative

assessment)

and Patient

Choice (3

locations)

No Got to make

sure TCs

work at full

capacity

Engaging acute

consultants -

how to sell you

services,

developing

clinical

champions.

PCTs have got

to sign up to

GPSIs

M PCT diagnosis

and treatment

centre. GPSI

service (main

TC due open

2005): just

one session a

week. P: 'we

refer to it as a

GPSI, an

enhanced

practice'

No -

marketed as

a

dermatolog

y GP clinic

Was seeing 12

patients per

session but has

fallen to 7-8 after

nursing staff

vacancy

P: extremely

beneficial to

patients. Putting

a second GP in

to expand

service.

Demand and

patient

expectation

seems to be

increasing all

round

Conflicting

information

between P + C

P: waiting list

reduced to

three weeks;

C: list reduced

initially but

referral rates

increased (from

initial three

weeks) waiting

times to 3-6

mths

No. Paid per

session

Been so

popular is a

victim of its

own success

- getting so

many

referrals are

struggling to

cope

Logistically

getting all

equipment in

place asap



Impact fairly

small to start

with

Type of TC TC

branding

Example of

modernisation

Difference in

productivity

Expectations

met

Impact on

waiting

times


challenges

now

Lessons for

new TCs

N Development

of pre-existing

service;

purpose built,

LPC

Signposted

as day unit

Benefits of

economies of

scale and

limited to

cataract

surgery. Staff

are willing to

experiment

Yes has met

productivity

targets set by

Patient Choice

Has met

expectations as

a testing ground

for streamlined

developments

from the ground

up

Have reduced

waiting lists

from 6 to 3

months

No (other than

very localised

temporary

arrangements

for junior staff)

C: problems

with

fluctuating

numbers

each week,

uneven

patient flows.

Planning and

maximising

use of weekly

system

(Patient

Choice)

Look carefully

at future

demand and

changes in

demand or else

will have excess

capacity and

large number of

days with too

few patients

O Virtual elective

centre, LPC

No - not

branded as

a diagnosis

and

treatment

centre, want

it to be seen

as part of

mainstream

hospital

Yes - quantifiable

in the reduction in

the length of stay

for knee

replacement from

12 to 5 days

Yes and no. In

some parts

good, in some

parts we've got

a lot more work

to do

Fee for service

in

ophthalmology

and general

surgery. Use the

BUPA rates and

pay 80% of that

Marketing to

take NHS

patients or

will have to

close as

premium on

the price to

pay for

empty

capacity;

theatre

efficiency and

recruiting

anaesthetists

Make sure your

scheduling is

right; start

early on job

descriptions

and

recruitment;

good

communication

all the time

(pre-

assessment,

theatres and

ward); have a

champion





Appendix 6 An example of a patient pathway

Referral with USS

Outpatients

Exclusions for day surgery

Male Age > 60 ASA Grade 3 Unfavourable USS Need for IO cholangiogram Previous abdominal laparotomy Patient to be given information leaflet from intranet

USS

Report on: - biliary tract - contracted gall bladder - gall stones - thick wall

Pre-operative assessment - to use staff assessment

guide

TCI date confirmed

(morning list)

Day of surgery - 7am admission - to admission lounge - walk to theatre - 1

st patient to be at theatre for

8.30am

Anaesthetic - Paracetamol 1g iv at induction - Paracoxib 40mg iv at induction - anti-emetics as per protocol

Recovery - 30 minutes - use of Pain and PONV scoring - avoid opioids if possible

Post operative care (ward) (8 hours)

- diet and fluids tolerated - analgesia - regular anti-emetic - ambulate patient

Discharge (Review by medical team post-op or nurse to contact medical team by phone) - pain control adequate - tolerating diet/fluid with no evidence of nausea or vomiting - no wound leakage - competent adult to help home and stay with overnight - access to landline

4 weeks post-op Telephone follow up by senior nurse

Discharged to GP

Daycase laparoscopic cholecystectomy

Patient visits 2 Surgeon Mr M… Anaesthetist Dr D… Pathway development lead S…

To be listed

Back to surgeon to agree date in

diary

Ward attend if necessary

One Stop

2 weeks prior to surgery

- health screening questionnaire (Pre-op team)

Note: USS = ultrasound scan; TCI = target-controlled infusions; PNV = post-operative nausea and vomiting

General practice



Appendix 7 Department of Health’s health reform framework

Source: Department of Health (2005f)



Appendix 8 Applying the Greenhalgh et al model to NHS treatment centres in general

Key questions Typical features of NHS treatment centres

1 The innovation

Key attributes of the innovation as perceived by

intended user:

(a) relative advantage Potentially high (separation of elective and emergency work and all ‘knock on’ benefits from that); perceived

improvements in quality and quantity of care, and in kudos for local NHS, Department of Health, and

Government; chance to alter patient pathways and professional roles

(b) compatibility Compatible with values of most clinicians although some staff view as part of the ‘break up’ of the NHS; patient

satisfaction likely to be very high as meets needs of fast and reliable access

(c) complexity The concept of TCs is simple to understand but implementation is complex (i.e. multi-disciplinary, multi-

professional, often reliant on complex realignments of staff and facilities)

(d) trialability Relatively easily trialable but not easy to evaluate longer-term and system-wide impacts formally

(e) observability Reasonably observable (e.g. high profile of pilot sites such as Central Middlesex Hospital’s Ambulatory Care and

Diagnostic Centre)

(f) reinvention (the extent to which the innovation

is changed or modified by the user in the process

of adoption and implementation)

High potential for reinvention

Key operational attributes:

(a) relevance to task High task relevance (i.e. fast and efficient treatment for patients)

(b) usefulness for task Potentially high usefulness in terms of improving patient care

(c) feasibility Variable feasibility, but by virtue of its adaptability and capacity for reinvention it can be made to be feasible just

about anywhere if other conditions permit

(d) implementation complexity High implementation complexity (in terms of numbers of ‘response barriers’ that must be overcome in order to be




implemented successfully)

(e) divisibility into components Possibly divisible, but usually adopted as a whole rather than incrementally

(f) nature of knowledge needed On the one hand mostly highly codifiable and transferable (e.g. patient pathways). On the other hand ,tacit and

sticky as regards local implementation

2 Adoption and assimilation

Who are the potential adopters and what are their

characteristics and needs?

Broad range of senior managers and senior clinicians with differing needs and expectations

What is the meaning of the innovation to intended

adopters?

For most, a way of improving and systematising patient care; for some, income generation for their organisation;

for others, building organisational/individual reputation; for some, a chance to promote new professional roles

What is the nature of the adoption decision? Authoritative

What are the concerns of adopters at:

(a) pre-adoption stage

(b) early-use stage

(c) experienced user stage, and to what extent

are they met?

Predominantly financial at all stages (with concerns regarding governance arrangements too):

(a) securing capital funding for project, persuading key staff to participate

(b) attracting sufficient patient numbers to remain viable

(c) uncertainty regarding wider policy environment and nature of ‘competition’ in the new NHS that ‘restricts

opportunities to adapt and refine the innovation to improve its fitness for purpose’ (see Greenhalgh et al, 2005;

p.9)

Typical pattern of assimilation process in

organisations

Outline business case for capital funding; building/renovating facilities; recruitment; securing ‘buy-in’ from key

staff in ‘host’ staff organisation and more widely from other organisations in local health economy. Often strongly

driven by project management until opening

3 Diffusion and dissemination

What is the nature of the networks through which

influence about the innovation is likely to diffuse?

Centrally-driven organisational innovation; spread mainly via vertical networks; but also spread ‘laterally’ as

competing trusts spot opportunities and stake a claim for a place in this bit of sun

Who are the main agents of social influence and

what are they doing?

Senior clinicians (typically some are sceptics, some champions) supporting (or challenging) TCs through their

clinical networks; chief executives of NHS trusts seeking to gain agreement and buy-in from their own staff and

leaders of other health care organisations locally, sometimes senior nurses (e.g. Site B)

4 The inner conext




What are the key structural features of the

organisation?

(a) size/maturity

(b) complexity/differentiation

(c) decentralisation

(d) slack resources

TCs have generally been adopted in established hospital units providing standard acute sector services, usually

large, mature, highly complex and often deeply differentiated internally (e.g. departmental and professional

‘tribalism’). The extent of decentralisation within NHS hospitals is typically limited and there are few slack

resources (although capital funding for TCs was provided centrally and NHS Modernisation Agency programme

was available to support local implementation; latterly a knowledge-sharing network, AmbiCentres International,

has been established)

What is the organisation’s absorptive capacity for

this type of knowledge? (a) skill mix; (b)

knowledge base; (c) transferable know-how; (d)

ability to evaluate the innovation

In general, a typical trust should have the clinical expertise and capital projects experience to initiate and plan a

TC. However, many trusts will have limited ability to manage the later necessary organisational change process

and evaluate the innovation (despite the fact that most hospitals are trying new things all the time!)

What is the organisation’s receptive context for

this type of change?

(a) leadership and vision

(b) values and goals

(c) risk-taking climate

(d) internal and external networks

Early adopters tended to be entrepreneurial and pioneers and saw TCs as an opportunity. These early TCs often

led by senior, well-networked clinicians. As TCs have become more common the nature of the enterprise - and

experiences of early adopters - have typically led to scaling back of original ambitions and more risk-averse

leadership from senior managers in ‘host’ trusts

What is the organisation’s readiness for this

specific innovation?

(a) organisational fit

(b) assessment of implications

(c) dedicated time/resources

(d) broad-based support

Very variable between trusts. Generally high and basic premise of separating elective and emergency work is

commonly accepted as a ‘good idea’. Implications for training, reconfiguration of services within trust as a whole

generally not well understood. Dedicated management and clinical time a ‘must’ and generally available. Support

has been mixed – some parts of organisation see TC as a threat (e.g. trade unions); others as an inevitable,

progressive step

5 The outer context

What is the nature and influence of the socio-

political climate?

Very strongly centrally-driven; TCs central part of NHS Plan and Government’s modernisation agenda. Patient

Choice a key component. The extent to which these policy aims are supported more generally unclear. Some

hostility to any independent sector involvement with TCs and concerns regarding perceived ‘break up’ of the NHS.

The considerable confusion in public (and staff) eyes with independent sector TCs is a problem for those




developing NHS-run TCs.

Are there any external incentives and mandates? Yes (e.g. national waiting time and capacity targets) as well as what is perceived in some NHS-run TCs as an

opportunity to attract revenue to their organisation

What are the prevailing norms from other

comparable (‘opinion leaders’) organisations?

Generally supportive but some concerns re clinical training implications and (see above) the perceived threat of

TCs as ‘privatisation of NHS through the back door’

6 Implementation and institutionalisation

What are the features of the implementation

process in terms of:

(a) human resources

(b) involvement of key staff

(c) project management

Typically requires (a) significant recruitment and/or training (often to new roles) and new skills in areas such as

marketing (b) essential to have broad support among senior clinicians (c) strong project management required

especially during early phases (e.g. business case, building projects). Presence of enthusiasts

(idealists/opportunists) at most trusts has been an important enabler

What measures are in place to capture and

respond to the consequences of the innovation

(e.g. audit and feedback)?

Variable. Some TCs lack a systematic approach to this although governance concerns from the ‘host’

organisations and TCs’ own desire to market their services on the basis of good outcomes data have served to

improve audit and feedback. Most TCs have well-established patient feedback surveys in place. Little strategic

assessment so far of impact of TCs on wider health economies

8 The role of external agencies

Are the developers linked with potential users of

the innovation at the development stage, and do

they share value systems, language and

meanings?

Some of the early adopters of NHS-run TCs worked with the original developers of the concept (e.g. US surgi-

centers or the Ambulatory Care and Diagnostic Centre) but later sites appear to have had less links. Little

evidence of developers within each TC linking with end users (i.e. patients). Other ‘users’ (e.g. GPs, PCTs)

sometimes little involved in the development stage of TCs but picture is mixed.

What is the capacity and role of the external

change agency (if any) to help organisations with

operational aspects of assimilation?

The NHS Modernisation Agency provided change management support and training, as well as a knowledge

sharing network, for the first few years of TC development. Regional groups were also established to support local

implementation. Responses to these initiatives were mixed. Unsure yet about the capacity and influence of

Ambicentres International

Who are the main external change agents and do

they show

(a) homophily?

It was the NHS Modernisation Agency programme managers (on behalf of Department of Health and

Government). At one level (e.g. corporate rhetoric) they do share corporate language, positive relationships etc.

At another (in terms of how TCs are framed - see Pope et al, 2006 - and also the tension between centre and

front-line) they do not




(b) positive relationships and client centredness?

(c) shared language and meaning?

Does the dissemination programme follow social

marketing principles?

(a) audience segmentation

(b) assessment of target group needs and

perspective

(c) appropriate message and marketing channels

(d) good programme management

(e) process evaluation

Centrally-driven dissemination. Major problem has been poor assessment of target needs and perspective. TCs

have - in part – been imposed either directly or indirectly (as a solution to central waiting time and capacity

targets). Quality of programme management has been mixed or poor. But overall dissemination has had little to

do with ‘social marketing principles’

What is the nature and quality of any linkage

relationship between the change agency and the

intended adopter organisations?

Participation in change agent-led activities was voluntary. Moved from a national (Modernisation Agency) to series

of regional programmes over time. On the other hand, once committed to a TC and it was part of the

performance targets for the trust, this was hardly voluntary as regards the other external agency, the

Department of Health



Appendix 9 Publications and presentations arising from this study

Publications

Bate SP and Robert G. 2006. ‘Build it and they will come’ – or will

they? Choice, policy paradoxes and NHS treatment centres. Policy

& Politics 34 (4): 651-672.

Gallivan S. 2005. Mathematical methods to assist with hospital

operation and planning. Clinical and investigative medicine 28(6):

326-30.

Gallivan S. 2006 (in press). Modelling the assignment of outpatient

examination rooms. The proceedings of the 31st meeting of the

European working group on operational research applied to health

service.

Gallivan S and Utley M. 2005. Modelling admissions booking of elective

in-patients into a treatment centre. Institute of Mathematics and

its Applications Journal of Management Mathematics 16: 305-315.

Pope C, Robert G, Bate SP, le May A and Gabbay J. 2006. Lost in

translation: a multi-level case study of the metamorphosis of

meanings and action in public sector organisational innovation.

Public Administration 84(1): 59-79.

Utley M, Gallivan S and Jit M. 2005. How to take variability into

account when planning the capacity for a new hospital unit. In J

Vissers and R Beech (eds.) Health operations management,

pp.46-161. London: Routledge.

Utley M and Gallivan S. 2004. Evaluating the new diagnosis and

treatment centres in the UK. In M Dlouhy M (ed.) Modelling

efficiency and quality in health care: the proceedings of the 29th

meeting of the European working group on operational research

applied to health services, pp.125-32.

Presentations

Bate SP, Robert G, Gabbay J, Pope C and Le May A. 2004. A new

design for local treatment? Early findings from a study of NHS

Treatment Centres. Third national Service Delivery & Organisation

conference: delivering research for better health services. London.

Gallivan S. 2005. Scheduling outpatient clinics, a rooks tour and the

Birkhoff von Neuman theorem. Paper presented to the 31st

meeting of the European working group on operational research

applied to health services. Southampton.



Gallivan S. 2005. International workshop on modelling health care

systems: linking operations and health services research.

University of British Columbia, Vancouver.

Jit M, Utley M and Gallivan S. 2005. Can a treatment centre reduce the

total bed requirements within a local health economy? Paper

presented to the 47th meeting of the Operational Research

Society. Chester.

Le May A, Gabbay J, Pope C, Robert G and Bate SP. 2005. NHS

treatment centres: case studies in the implementation of an

innovative policy into NHS practice. 6th international conference on

the scientific basis of health services. Montreal.

Pope C, Le May A and Gabbay J. 2006. Chasing chameleons, chimeras

and caterpillars: researching the implementation of an

organisational innovation in the National Health Service. Paper

presented to the International conference on organisational

behaviour in health care. University of Aberdeen. (Received ‘best

research paper’ prize.)

Pope C, Robert G, Bate SP, le May A and Gabbay J. 2004.

Metamorphosis of meanings and discourse in organisational

innovation and change processes: a multi-level case study of NHS

Treatment Centres. Paper presented to 6th international

conference on organizational discourse: artefacts, archetypes and

architexts. Amsterdam.

Robert G, Bate S.P, Pope C, Gabbay J and Le May A. 2005. Processes

and dynamics of identity formation in professional organisations:

longitudinal case studies of a new organisational form. Paper

presented to the 21st European Group on organisational studies.

Berlin.

Utley M and Gallivan S. Evaluating the new diagnosis and treatment

centres in the UK. Paper presented to the 29th meeting of the

European working group on operational research applied to health

services. Prague.

Disclaimer This report presents independent research commissioned by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, the NIHR SDO programme or the Department of Health. The views and opinions expressed by the interviewees in this publication are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, the NIHR SDO programme or the Department of Health Addendum This document was published by the National Coordinating Centre for the Service Delivery and Organisation (NCCSDO) research programme, managed by the London School of Hygiene & Tropical Medicine. The management of the Service Delivery and Organisation (SDO) programme has now transferred to the National Institute for Health Research Evaluations, Trials and Studies Coordinating Centre (NETSCC) based at the University of Southampton. Prior to April 2009, NETSCC had no involvement in the commissioning or production of this document and therefore we may not be able to comment on the background or technical detail of this document. Should you have any queries please contact [email protected].

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