Can foundation trusts survive and where do their loyalties lie?

A gap in areas lies between the governors and the non-executive directors of foundation trusts, writes David Walker. Photograph: Martin Argles for the Guardian

The polite word is 'hybrid'. The less polite is 'incoherent'. Either way, NHS foundation trusts are based on two contradictory visions of how they should operate and who should call the shots, and the 2012 Health Act is increasing the tension between them.

Ten years ago, Labour had a wacky idea. Instead of making primary care – the part of the NHS closest to people — more accountable, it would inject democracy into the providers of healthcare in the hospitals, ambulance, and mental health services. They, not the GPs, would have elections. The notion is now looking odder and odder, partly because of the competitive pressures stoked by the Cameron coalition's health act and partly because it's commissioning that needs accountability most.

No wonder, then, you start to overhear backstairs conversations asking whether the foundation trust (FT) model can survive. One half of the hybrid is the community, the people using the service, staff and patients themselves and it is they who elect FT governors. Alan Milburn, the Labour health secretary, dreamily talked of mutualism – but then set up a regulator, Monitor, to enforce strict business principles on FTs.

So the other half of the FT model is hardheaded commerce, profit and loss and earnings before interest, depreciation and amortisation. FTs are meant to behave like businesses, going for growth and profit. How are governors meant to square their desire for a local service with the FT board's concern to balance the books by closing a clinic here or a much-loved ward over there?

Democracy and profitability may be fated to war. Paul Hackett, director of the Smith Institute, notes 'all public institutions face tensions between representation and effectiveness', including school governing bodies and councils themselves. Smith, a centre-left thinktank, has just teamed up with the Association of Chartered Certified Accountants to paint a picture of FT governance.

It's healthier than might have been thought, confirming surveys by Monitor. Total numbers involved have actually been growing though FT governors tend to be older and retired; half their elections are not contested. Still, many thousands of people, embedded in local areas across England (the experiment did not extend to the rest of the UK), contribute vast amounts of time and energy to their mental health, community and hospital services through membership of a trust.

The Smith report warns against generalisation – FTs vary widely in their levels of activism, and in how close governors get to board decision-making, especially in matters of finance. A yawning gap in many areas lies between the governors and the non-executive directors, who are not representative of the area but on the board to ensure trusts operate efficiently and effectively.

The Tories, embarrassed at the complete absence of accountability from their original ideas for clinical commissioning by GPs, inserted more powers for FT governors in the 2012 act; they now shadow many of the decisions taken by FT boards, without being paid and without the support apparatus boards tend to have.

Ahead lie problems. Governors are the public and want to operate in the open.

But how can FTs compete with private providers if their cost schedules and profit assumptions are declared in advance? Virgin of course has no governors. Its shareholders are institutional investors who play no part in executive decision taking unless profits go down. What if governors, responsive to staff and patients, opt for a lower rate of return than the board, mindful of competitive pressures? Who should have the last word?

If governors represent one area, what role should they play if an FT acquires healthcare responsibility in another area and the notion of 'local' gets stretched? In London, the executives of better-performing FTs are supposed to lend a hand to trusts in difficulty (most of them still in the notional pipeline to becoming FTs): governors might object to 'their' managers being distracted from serving the local area.

Do governors have any role in bidding for contracts from clinical commissioners? Or from councils? Now that public health has shifted to councils, some FTs are fighting for contracts from the town hall: is the local authority or the FT governing council more 'representative' of an area? The better FT governing councils are those that include elected councillors, but where now do their primary loyalties lie?

David Walker is a non-executive director of a foundation trust; the views expressed here are his own

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NHS trusts are not getting the most out of their MRI scanners

MRI scanners should be used seven days a week for at least 10 hours a day. Photograph: Mark Kostich/Getty Images

Extending the range of hospital services provided at weekends is becoming an increasingly important health policy. Having identified this as a priority, NHS England medical director Bruce Keogh has set up a forum focusing on creating a seven-days-a-week NHS, with its findings due to be published later this year. This review comes after a welter of professional advice, and studies in recent years have identified that patients admitted to hospital at weekends have significantly worse outcomes than those admitted during the week.

In 2011, a Royal College of Surgeons study into emergency surgical patients and the Dr Foster Hospital Guide both highlighted how the closure of services at weekends was a significant factor in patient outcomes. A lack of routine diagnostic services was specifically highlighted as having an adverse effect, creating a bottleneck for getting patients to effective treatment.

Currently in some trusts, scanning services are still run as a weekday limited-hours service, and the implication of this is that capacity is not keeping pace with demand. Alliance Medical's research and analysis of available data across the NHS shows that more than a quarter of NHS trusts (37 of 135) have a very low utilisation rate of below 5,000 MRI scans per machine per year. By contrast, across the 20 NHS static imaging centres run by Alliance Medical, 14 operate seven days a week for at least 10 hours a day. On sites with high throughput, these are staffed at two radiographers per scanning hour to maximise patient throughput. The services are integrated with being able to offer clinical reporting services, which can provide access to clinicians in the UK and other time zones for urgent reports.

With volumes of MRI scans increasing by around 10% a year, there is a strong financial case for extending hours and improving productivity through the most efficient utilisation of scanning services.

There is nothing revolutionary in achieving this and trusts should look at extending hours in scanning as an "easy win" towards the achievement of a seven-days-a-week NHS.

Flexible staff contracts that routinely consider scanning as a seven-day service are fundamental, and this is an area where the Agenda for Change may have inadvertently created disincentives for some trusts. The rates of unsociable hours salary premiums, as well as the difficulty of dovetailing with consultant and junior doctor job planning, can mean a sharp escalation in staff costs. But, with demand for scans rising, ensuring full utilisation of the established units has to be a more efficient option than simply setting up new scanning centres, each running below capacity.

This is an area where independent healthcare providers such as Alliance Medical have a distinct advantage because their staff contracts assume a routine operation across a seven-day rota with standardised working hours.

Absolutely key to the productivity of radiographers is the team of administrative staff that supports them. A good support team manages the back-office tasks, freeing radiographers to deliver frontline patient care, and works to maximise utilisation by proactively filling appointment slots.

Good performance data and support systems also play an important role in the management of diagnostic lists and are currently lacking in many areas. Through its partnering arrangements with the NHS, Alliance Medical measures patient throughput and has introduced key performance indicators, including hours of uptime and patients scanned per hour. These are measured and reported daily right up to board level. By sharing knowledge in this way, workflows can be standardised, minimising duplication of effort and data entry to ensure a consistently high level of patient care and throughput. Systematically reviewing capacity versus demand enables staffing to be balanced to mirror the hospital's wider needs. 

Another important factor is negotiating hard on maintenance and service contracts. Alliance Medical negotiates for routine maintenance work to be undertaken out-of-hours (which, under seven-day working, means overnight) and as a result they have MRI scanners operating at 99.42% of opening hours.

Improving access to scanning services makes sense both financially and in terms of meeting the expectations that will be placed on providers over the coming year. It entails a relatively simple set of processes and should be one of the first areas looked at by acute trusts.

David Loasby a former NHS acute trust chief executive and UK business development director for Alliance Medical Limited.

This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.

View the original article here

NHS trusts are not getting the most out of their MRI scanners

MRI scanners should be used seven days a week for at least 10 hours a day. Photograph: Mark Kostich/Getty Images

Extending the range of hospital services provided at weekends is becoming an increasingly important health policy. Having identified this as a priority, NHS England medical director Bruce Keogh has set up a forum focusing on creating a seven-days-a-week NHS, with its findings due to be published later this year. This review comes after a welter of professional advice, and studies in recent years have identified that patients admitted to hospital at weekends have significantly worse outcomes than those admitted during the week.

In 2011, a Royal College of Surgeons study into emergency surgical patients and the Dr Foster Hospital Guide both highlighted how the closure of services at weekends was a significant factor in patient outcomes. A lack of routine diagnostic services was specifically highlighted as having an adverse effect, creating a bottleneck for getting patients to effective treatment.

Currently in some trusts, scanning services are still run as a weekday limited-hours service, and the implication of this is that capacity is not keeping pace with demand. Alliance Medical's research and analysis of available data across the NHS shows that more than a quarter of NHS trusts (37 of 135) have a very low utilisation rate of below 5,000 MRI scans per machine per year. By contrast, across the 20 NHS static imaging centres run by Alliance Medical, 14 operate seven days a week for at least 10 hours a day. On sites with high throughput, these are staffed at two radiographers per scanning hour to maximise patient throughput. The services are integrated with being able to offer clinical reporting services, which can provide access to clinicians in the UK and other time zones for urgent reports.

With volumes of MRI scans increasing by around 10% a year, there is a strong financial case for extending hours and improving productivity through the most efficient utilisation of scanning services.

There is nothing revolutionary in achieving this and trusts should look at extending hours in scanning as an "easy win" towards the achievement of a seven-days-a-week NHS.

Flexible staff contracts that routinely consider scanning as a seven-day service are fundamental, and this is an area where the Agenda for Change may have inadvertently created disincentives for some trusts. The rates of unsociable hours salary premiums, as well as the difficulty of dovetailing with consultant and junior doctor job planning, can mean a sharp escalation in staff costs. But, with demand for scans rising, ensuring full utilisation of the established units has to be a more efficient option than simply setting up new scanning centres, each running below capacity.

This is an area where independent healthcare providers such as Alliance Medical have a distinct advantage because their staff contracts assume a routine operation across a seven-day rota with standardised working hours.

Absolutely key to the productivity of radiographers is the team of administrative staff that supports them. A good support team manages the back-office tasks, freeing radiographers to deliver frontline patient care, and works to maximise utilisation by proactively filling appointment slots.

Good performance data and support systems also play an important role in the management of diagnostic lists and are currently lacking in many areas. Through its partnering arrangements with the NHS, Alliance Medical measures patient throughput and has introduced key performance indicators, including hours of uptime and patients scanned per hour. These are measured and reported daily right up to board level. By sharing knowledge in this way, workflows can be standardised, minimising duplication of effort and data entry to ensure a consistently high level of patient care and throughput. Systematically reviewing capacity versus demand enables staffing to be balanced to mirror the hospital's wider needs. 

Another important factor is negotiating hard on maintenance and service contracts. Alliance Medical negotiates for routine maintenance work to be undertaken out-of-hours (which, under seven-day working, means overnight) and as a result they have MRI scanners operating at 99.42% of opening hours.

Improving access to scanning services makes sense both financially and in terms of meeting the expectations that will be placed on providers over the coming year. It entails a relatively simple set of processes and should be one of the first areas looked at by acute trusts.

David Loasby a former NHS acute trust chief executive and UK business development director for Alliance Medical Limited.

This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.

View the original article here

NHS trusts are not getting the most out of their MRI scanners

MRI scanners should be used seven days a week for at least 10 hours a day. Photograph: Mark Kostich/Getty Images

Extending the range of hospital services provided at weekends is becoming an increasingly important health policy. Having identified this as a priority, NHS England medical director Bruce Keogh has set up a forum focusing on creating a seven-days-a-week NHS, with its findings due to be published later this year. This review comes after a welter of professional advice, and studies in recent years have identified that patients admitted to hospital at weekends have significantly worse outcomes than those admitted during the week.

In 2011, a Royal College of Surgeons study into emergency surgical patients and the Dr Foster Hospital Guide both highlighted how the closure of services at weekends was a significant factor in patient outcomes. A lack of routine diagnostic services was specifically highlighted as having an adverse effect, creating a bottleneck for getting patients to effective treatment.

Currently in some trusts, scanning services are still run as a weekday limited-hours service, and the implication of this is that capacity is not keeping pace with demand. Alliance Medical's research and analysis of available data across the NHS shows that more than a quarter of NHS trusts (37 of 135) have a very low utilisation rate of below 5,000 MRI scans per machine per year. By contrast, across the 20 NHS static imaging centres run by Alliance Medical, 14 operate seven days a week for at least 10 hours a day. On sites with high throughput, these are staffed at two radiographers per scanning hour to maximise patient throughput. The services are integrated with being able to offer clinical reporting services, which can provide access to clinicians in the UK and other time zones for urgent reports.

With volumes of MRI scans increasing by around 10% a year, there is a strong financial case for extending hours and improving productivity through the most efficient utilisation of scanning services.

There is nothing revolutionary in achieving this and trusts should look at extending hours in scanning as an "easy win" towards the achievement of a seven-days-a-week NHS.

Flexible staff contracts that routinely consider scanning as a seven-day service are fundamental, and this is an area where the Agenda for Change may have inadvertently created disincentives for some trusts. The rates of unsociable hours salary premiums, as well as the difficulty of dovetailing with consultant and junior doctor job planning, can mean a sharp escalation in staff costs. But, with demand for scans rising, ensuring full utilisation of the established units has to be a more efficient option than simply setting up new scanning centres, each running below capacity.

This is an area where independent healthcare providers such as Alliance Medical have a distinct advantage because their staff contracts assume a routine operation across a seven-day rota with standardised working hours.

Absolutely key to the productivity of radiographers is the team of administrative staff that supports them. A good support team manages the back-office tasks, freeing radiographers to deliver frontline patient care, and works to maximise utilisation by proactively filling appointment slots.

Good performance data and support systems also play an important role in the management of diagnostic lists and are currently lacking in many areas. Through its partnering arrangements with the NHS, Alliance Medical measures patient throughput and has introduced key performance indicators, including hours of uptime and patients scanned per hour. These are measured and reported daily right up to board level. By sharing knowledge in this way, workflows can be standardised, minimising duplication of effort and data entry to ensure a consistently high level of patient care and throughput. Systematically reviewing capacity versus demand enables staffing to be balanced to mirror the hospital's wider needs. 

Another important factor is negotiating hard on maintenance and service contracts. Alliance Medical negotiates for routine maintenance work to be undertaken out-of-hours (which, under seven-day working, means overnight) and as a result they have MRI scanners operating at 99.42% of opening hours.

Improving access to scanning services makes sense both financially and in terms of meeting the expectations that will be placed on providers over the coming year. It entails a relatively simple set of processes and should be one of the first areas looked at by acute trusts.

David Loasby a former NHS acute trust chief executive and UK business development director for Alliance Medical Limited.

This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.

View the original article here