Amid a welter of simultaneous policy initiatives, treatment centres were a top-down NHS innovation that became subverted into a multiplicity of solutions to different local problems. This highly readable account of how and why they evolved with completely unforeseen results reveals clear, practical lessons based on case study research involving over 200 interviews. Policy makers, managers and clinicians undertaking any organisational innovation cannot afford to ignore these findings.
Evidence-based practice in social care and health is widely promoted. Making it a reality remains challenging, partly because practitioners generally see practice-based knowledge as more relevant than empirical research. A further challenge regarding the creative, contextual use of research and other evidence including lived experience and practice-based knowledge is that practitioners, especially in frontline care services, are often seen not as innovators, but recipients of rules and guidelines or followers of pre-determined plans. Likewise, older people are not generally recognised as co-creators of knowledge, learning and development but as passive recipients of care, or objects of research.
This study aimed to address the above issues, through a collaborative and appreciative endeavour involving researchers; social care and health practitioners; managers; older people and carers in 6 sites across Wales and Scotland.
We used participatory action research methodology, applying a dialogic storytelling approach, which enabled participants to explore and address 7 already published research-based ‘Challenges’ regarding what matters most to older people with high-support needs.
Participants discovered and addressed five elements required in developing evidence-enriched practice; the creation of supportive and relationship-centred research and practice environments; the valuing of diverse types of evidence; the use of engaging narratives to capture and share evidence; the use of dialogue-based approaches to learning and development; and the recognition and resolution of systemic barriers to development.
Discussion and conclusion:
Although existing literature covers each element, this project was novel in collectively exploring and addressing all five elements together, and in its use of multiple forms of story, which engaged hearts and minds, positive outcomes were achieved.
The public’s top concern about the NHS is waiting for treatment. (DH, 2000a, para 12.1, p 101)
The national Treatment Centre programme is entering a significant new phase of its development. The change provides a simpler name for the public and for patients at this key moment. It does not reflect any change in the core characteristics of schemes, or the overall objectives of the programme. From now on all national publicity will refer consistently to Treatment Centres. All the Independent Sector schemes will brand themselves Treatment Centres under contract. It would clearly help build consistency across the programme and help build public recognition and acceptance (especially with patient choice in mind) if the NHS schemes adopt the same name. (DH, 2003b)
The “war on waiting” had been at the core of the NHS policies of the Labour government since 1997 (Harrison and Appleby, 2005) and set the overall policy context for TCs during our period of research. The NHS Plan of 2000 marked a shift away from reducing the number of people waiting and onto the time they waited, by introducing new investments and targets along with a wide range of policies to help transform the way that elective care was provided. The new emphasis was on TCs, day surgery, the NHS Modernisation Agency, specialty programmes such as orthopaedics and ophthalmology (an early focus for TCs) and ‘Patient Choice’. The government also supported the development of new services in community settings; it also set targets for increasing the overall number of hospital beds and introduced a star-rating system for trusts’ overall performance in which five out of nine “key targets” were related to waiting.
‘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.’ (senior clinical manager, St Urban’s)
Chapter Two highlighted the paradox that, considering all eight sites were part of the same NHS and engaging with the same national innovation programme, their initial circumstances had almost nothing in common with each other. However, they all had local justifications for opening a TC that were the result of complex ‘negotiations’ between different ‘players’ at each site, each of whom interpreted the innovation differently. At each site, key players in the early phases of the development of the TCs contested their understandings and definitions of a TC and what it might mean for the organisation. The tussles, disagreements and bargaining that would shape the resulting TCs were not simple interprofessional (often referred to as “tribal”) battles between, say, doctors, managers and nurses. Rather than splitting along professional lines, they seemed rather to fall into four types of player, namely opportunists, pragmatists, idealists and sceptics, who were to be found in varying proportions in each of the sites. Each type had a role in determining the fate of the innovation, using different aspects of the local initial conditions in each site to argue the case for or against developing a TC (Pope et al, 2006).1
Opportunists saw TCs as a chance to do something (rebuild, expand, renew) that they might not otherwise have the chance to do, which was often an innovation they had already been planning or developing.
Whatever the eventual problems, all of the TCs in our sample had, more or less explicitly, a group of enthusiasts, mainly the ‘idealists’ (see Chapter Three), who generated the momentum and the energy to try to bring about innovations and improvements in care in the TCs. For them, the tumult of national policy changes and failing local business models was background noise as they strove to introduce practice innovations for their own TC, invariably meeting local resistance from one source or another even when other sites might regard the change as unexceptionable. This chapter examines those innovations in care, 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.
Despite the mixed motives for the innovation and all the difficulties that emerged once they were running, most of our case study TCs increased the throughput of patients and all were thought by the wider health economy to be important contributors to achieving not only waiting list targets, but also providing greater patient choice. For example, Ruckworth, for all its difficulties, was nevertheless helping its partner trusts to meet the government’s stringent waiting list targets. As our fieldwork was ending, an option appraisal there, 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.
When the UK government announced in 2000 that over 40 major diagnosis and treatment centres (DTCs) would be introduced across the National Health Service (NHS), the idea was generally acclaimed as one whose time had come. DTCs were an innovative way of providing healthcare to thousands of patients with specific healthcare needs (see Appendix 1). Mostly purpose-built, DTCs would be designed to ensure that elective patients requiring straightforward diagnosis or treatment would avoid long waits and unnecessary hospital stays. DTCs would, moreover, spearhead the modernisation of ways of working in the NHS, another equally important priority that included the redefinition of professional roles and the spread of pre-defined pathways of patient care. Hospitals throughout the NHS rushed to get involved. Within a year of the original announcement, eight DTCs were already up and running, and by the end of 2006 there were 46 in place, with many more being planned. Yet, as with so many healthcare innovations, these DTCs or treatment centres (TCs), as they were later relabelled, did not turn out quite as central government had originally envisaged.
Although TCs are now an established part of the NHS, the lessons that we learned from studying their introduction remain poignantly relevant, since similar large-scale initiatives in the organisation and delivery of healthcare are – and are always likely to be – a continuing feature of central government policy making. There are many important questions one could ask specifically about TCs, such as whether the policy to establish them has been successful, how the new arrangements have affected patient experience and outcomes, whether professional roles changed for the better, what works or does not work in the management of elective patients and whether private sector involvement has improved the service.
Considering that this was supposed to be a unified national initiative, it was astonishing just how varied the eight case study sites turned out to be, not only in the manner in which the innovation occurred, but also in the configurations of the TCs themselves. Looking back, it should have been obvious that they would come in all shapes and sizes. After all, every previous central innovation of this kind, such as day surgery units in the 1980s or NHS Walk-in Centres in the 1990s, had spawned a mass of varied models. Indeed the Modernisation Agency had made clear that TCs should vary depending on local circumstances. But what they had in mind was the rational redesign of the same basic principles according to the likely demand for particular surgical services in localities with dissimilar populations. In fact the huge variety that emerged depended more on the happenstance of local organisational culture, politics, finances, relationships and buildings than on any rational analysis of local healthcare needs.
In order to understand this variety, and also to lay the foundations for understanding just what it was that shaped the innovation and its varied fate over time in different localities (see Table 2.1), we start by reviewing the initial conditions at each site. What kind of organisations were these NHS trusts that decided to become part of the early TC movement? How and why were they in a position to do so? We look here at each site in turn, examining both the internal circumstances and the external environment of each.
When The NHS Plan was launched in 2000, TCs were a promising organisational innovation based largely on ideas stemming from a high profile prototype, rather than good research evidence. But their time had come and by 2003, as our study commenced, strong political and organisational forces were spearheading their rapid diffusion in the NHS as an attempt to reduce waiting times and waiting lists for common elective procedures and to foster new forms of patient-centred care. This was all part of a much wider government drive to modernise the organisation and delivery of NHS services, which meant that NHSTCs were launched into the complex milieu of sweeping changes. Some of those changes were always bound to impact on the fledgling TCs (see Chapter Four); they included the encouragement of independent sector TCs, by such measures as the introduction of the ‘G-Supp’ as part of a wider governmental push towards involvement of the private sector; Payment by Results as part of stimulating improvements in organisational performance; and Patient Choice and ‘Choose and Book’ as part of the desire to empower patients. As a result, the story of TCs was not about a single innovation and its impact on services, but about organisational responses to a maelstrom of modernisation. Nevertheless, the dedicated extra funding and the advice from sources such as the Modernisation Agency’s ‘learning events’ gave an opportunity for local developments that, although often very different from the Department of Health’s ideal, reflected many of its intended principles. The Department might not always have things its own way but the TC programme did stimulate local change that might otherwise not have occurred.
‘… the revolution in care that you have pioneered here is to be applied all over the country.’ (former Prime Minister Tony Blair in a speech at the Ambulatory Care and Diagnostic Centre [ACAD], Central Middlesex Hospital, London, February 2001)
In a traditional hospital, the patient is certainly central to diagnostic and therapeutic preoccupations, but not to the organization. Indeed, the physician and the nursing staff are at the centre of the organisation…. The order of organisational priorities is reversed in an ambulatory surgery unit. This substantive organisational revolution is even more: it is indeed a genuine cultural revolution. (De Lathouwer, 1999)
The ACAD … is … a building capable of doing the work of a DGH [district general hospital] two to three times larger. (Black, 1999, p 4)
The concept of the treatment centre (TC) had roots that existed well before the 2000 NHS Plan that promulgated the scheme. The model of ambulatory surgical centres and other forms of ‘focused factories’ (Casalino and Robinson, 2003; Casalino et al, 2004), which had existed in US healthcare since the 1970s, had meant that neither the archetype nor its context was wholly new to the NHS. Indeed five planned ambulatory care centres in England, two of which subsequently became part of the TC programme, were discussed in a report in the mid-1990s (NHS Estates, 1996, p 4). But it was the Ambulatory Care and Diagnostic Centre (ACAD) opened at the Central Middlesex Hospital in North West London in 1999 that was most cited as the prototype for the TC programme.
For all the optimism that surrounded the opening of the eight TCs we were following, by 2006, when our three-year study ended, St Urban’s had closed and Ruckworth was on the verge of doing so (see Table 2.1, Chapter Two). Three of the others (Robbleswade, Stanwick and Northendon) were in deep difficulties due to a paucity of patients and were in discussions about selling space and/or capacity to the independent sector. (Since then, however, they have resolved their problems in their different ways and are still, in 2010, operating as NHS TCs.1) Only three of the eight were functioning in 2006 comfortably within the NHS as part of the NHS TC programme. Two of these, Pollhaven and Lakenfield, were relatively small-scale initiatives that had been absorbed back into their host trusts, but were still attempting, with differing levels of success, to practise the ideals of re-engineered care pathways that separated elective and emergency care, increased activity and improved patient experience. Only one of the eight, Brindlesham, appeared in 2006 to have weathered the storm to emerge as a stand-alone unit that largely mimicked the early ACAD and exemplified key elements of the original policy model of what an NHSTC should be. What were the reasons for the ways the TCs turned out at the end of our study? To a large extent the answer lay in the available capacity of the hospitals in a TC’s catchment relative to the total number of patients. At one extreme, Ruckworth, Stanwick and St Urban’s 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 Chapter Four), and the effects were devastating.