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Cherry-picking and clinical linkages

by Rob Findlay

Doing surgery? Then you need anaesthetics on-site. Obstetrics? Then you need paediatrics.

Acute care is a tangled web of interdependent services, joined by so-called “clinical linkages”. Pull out something innocuous-looking, such as physiotherapy, and the whole thing collapses.

These clinical linkages were all mapped out in an earlier post, and Roy Lilley picked it up in his discussion about competition and regulation (as did Paul Leake). His argument was that competition in healthcare provision could lead to these clinical linkages being unpicked, with disastrous results; therefore any local service reconfigurations would need to be managed (and not left to the forces of competition) in order to preserve these clinical linkages.

So how real is this threat?

Let’s start by sketching out the scenario we are worried about. A healthcare provider (it doesn’t really matter if they are NHS or private) sets up a new elective facility, which attracts work away from the neighbouring NHS acute hospital. This destabilises the NHS hospital and triggers the closure of its acute services (including A&E), much unhappiness for local people, and a political row.

There are three possible ways in which the new provider could destabilise the old:

  1. by financial cherry-picking: diverting away from the old provider a lot of highly-profitable elective work that had been subsidising the loss-making clinically-linked acute services;
  2. by deskilling: diverting away a lot of elective activity, so that clinicians at the old provider are no longer seeing a big enough caseload and become deskilled, so that those clinicians can no longer provide a safe acute service on which other acute services depend;
  3. by poaching: recruiting clinicians away from the old provider, causing the closure of a service on which other acute services depend.

In the Parliamentary committee debates on the Health and Social Care Bill, there was quite a lot of discussion of the problems that might be caused by “cherry-picking”. Monitor responded to these concerns in two ways: firstly to point out that if the problem is that elective procedures are more profitable than non-elective ones, then the solution is to change the tariff price and remove the distortion; and secondly that if economic destabilisation of acute services is the possible result, then Monitor can designate those services as essential and allow extra funding for them.

I would add a further point: it would be rash to assume that elective care is always profitable and acute care is always loss-making. So much in healthcare is characterised by gross and unexplained variations, and so there are likely to be many highly-profitable acute non-elective services, just as there will be many highly-loss-making elective services.

Deskilling is more pernicious, and would not be solved by flinging money at designated services. If surgeons are twiddling their thumbs all day because their elective workload has disappeared down the road, they are not going to be as practiced when surgical emergencies come in. Recruitment and retention would also go to pot. If you lose acute surgery, then acute medicine is at risk and so is A&E. What can be done?

Well, the first question to ask is: where is the new provider going to get its doctors from? In the middle of London, it is quite possible to run a hernia factory from 9-5, Monday to Friday, keep a whole team of surgeons busy, and still leave plenty of elective work around for the rest of London’s NHS doctors; deskilling would not happen in that scenario. But could you do the same in Northampton or Stoke? In practice, you’d probably be using the same NHS doctors who work at the local NHS hospitals, and so they wouldn’t be deskilled, just maintaining their skills on a different hospital site.

For the sake of argument, though, let’s say you did manage to set up an elective factory in the shires without using doctors from the local NHS. Perhaps your medical staff have been brought back from retirement, or want to work family-friendly hours. Would that not pose a threat to the local NHS hospital? Indeed it might. But how might the NHS hospital respond? They could do nothing, and let their surgeons twiddle their thumbs on full pay, but that would be perverse. A more sensible response would be to make their surgeons available to the new provider on attractive enough terms, which sidesteps the deskilling problem and replaces lost income. So it looks as if the old provider could respond to the deskilling threat, and head it off.

What about the third threat: poaching? Well the short answer is that nobody is irreplaceable. The old hospital can just recruit some new doctors. And if the service is so unattractive that it is impossible to recruit, then the old hospital’s problems run much deeper than the arrival of a new elective provider.

So we have seen how a degree of flexibility by the old provider can help sidestep the threat of destabilisation by the new. But we have tacitly assumed in this scenario that both the new and old providers are traditional monoliths who operate hospital buildings, and employ clinical staff, and contract with the NHS commissioners.

Now let’s imagine a world in which those three functions are unbundled. One possible way of doing this would be for the doctors in the old NHS hospital to establish themselves as Chambers and contract directly with commissioners; then the Chambers pays the hospital for the buildings, nurses, diagnostics and so on. Now we can see how much easier it would be to avoid the deskilling problem, which was the most serious challenge we faced above.

Because each Chambers could work across multiple hospital sites, it could respond much more flexibly than a traditional hospital service that was anchored to its buildings. If deskilling ever became an issue, the Chambers could redeploy clinicians across different hospital sites to head off the problem. It could, for instance, supply the clinicians needed by the new provider, including (where it made sense) retired or family-committed doctors.

So it is far from clear that clinical linkages are necessarily threatened by competition in healthcare provision. And even if they are, a flexible and competitive provider market could respond by unbundling provider functions in a way that unties people from buildings.

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