University Hospital Southampton NHS Foundation Trust
Paula joined the trust as chief executive in September 2018, having been chief executive at the Royal Surrey County NHS Foundation Trust in Guildford and before that at Sussex Community NHS Foundation Trust. Paula began her career as a pharmacist working in the community, hospitals and at health authorities, before moving into general management and her first board position at Kingston Hospital. Since then she has spent time on the boards of commissioners and providers, including director of transformation at Frimley Park Hospital NHS Foundation Trust.
I am really proud to be chief executive of a hospital that combines an excellent district general hospital (DGH) with some superb specialised services. I feel no less excited by the DGH side of the business than I do by those services that can only be delivered in a specialist centre. The clinicians and frontline staff that work here do not differentiate either. Most of them work in standard DGH services as well as super-specialised and it is the cross over that engages them. I get quite vexed about the rhetoric that you can only get the level of care and outcomes that we see in Southampton, in London trusts.
Creating interesting and varied roles for staff
I think that there is a direct correlation between staff involvement in the trust and the quality of outcomes for patients. Recently, our staff developed the trust’s mission and reflected what it is like to work at University Hospital Southampton (UHS) in the words they chose: "University Hospital Southampton; together we care, innovate and inspire". People want to work here because it offers the variety that you get within a large organisation, with a mix of generalisation and specialisation. We make sure the environment allows them to have freedom to innovate, an opportunity to work with inspirational people in an organisation that cares about people – both patients and staff.
Increasingly, we are working and learning from the rest of the system, considering our patients as people holistically rather than a series of illnesses. This should prevent patients with long-term conditions 'bouncing' around between specialties. It is something we already do with a number of our specialised services where we care for the person, their family and carers in really difficult circumstances.
Managing risk in a changing commissioning system
The differences between negotiating with local and specialised commissioners are not that great, although both have their tensions in managing the affordability of services with increasing demand. These differences might become more apparent, however, as the changes in the commissioning landscape develop at different paces, with the move to population and blended payments happening more rapidly at local STP/ICS level than is realistic for specialised commissioning. We are worried about the impact of these changes on us as a large specialist provider with a DGH. For example, delegating specialist commissioning to an ICS without a large specialist hospital will impact on those systems with a hospital like UHS within its catchment. The size of the system footprint won’t be appropriate for certain services.
It could mean that the commissioners that the provider has to deal with are fragmented and small – as are the populations that they commission for, meaning that some pathways that need extensively large populations may be at risk. It may be better to build it from the ground up – looking pathway by pathway to see what opportunities there are to share the risk.
There is a direct correlation between staff involvement in the trust and the quality of outcomes for patients.
The risk that exists for us comes from the difference between the current spend on specialised commissioning and the budget available to the commissioners. There is a danger that this is played out through ICSs, which are too small to hold that risk, passing it on to the provider. From a business perspective we cannot separate specialised from DGH service delivery so both the DGH and specialised services would have to take a hit – after all they are delivered by many of the same people, with patients quite often passing between the two.
In Hampshire and the Isle of Wight (HIOW) we are proposing a different solution. We are creating an integrated care partnership (ICP), which aligns with our STP principal that ICPs sit around the population of the acute trust. For UHS, this population is greater even than our STP at around three to five million and therefore needs to include other partners as well as those in our STP, e.g. Dorset providers, Salisbury and the specialised commissioners for those populations. It will include our children's hospital and support some of our wider networks beyond HIOW such as stroke, neonatal, pathology, radiology and support our genomics.
This population level feels like the right place to start because if we are going to make pathway changes to manage the specialised commissioning risk, it will need to involve these partners and we think if we do not have something like this in place our ambitions for change at this level may falter.
Avoiding rushed contract changes
Originally there was a race to get HIOW to ICS status by April 2020. There are two reasons for not doing that – one is the size of this organisation, because if you want it to be meaningful on the front line, that means we have to bring 11,600 people to a different place in a few months. This is not realistic – we will need longer than this to bring our people with us and make any changes stick.
There is a huge opportunity for us to shift the dial on self-care, prevention and wellbeing, but this needs to be done with partners, patients and future patients, so you can get a population-level change rather than just a provider change. Also, at the moment, because the trust has operated under payment by results so successfully over so many years, it will take a while to get the whole organisation to adjust its thinking.
We are working out with our commissioners, local and specialist, to figure out what the best way to move to a population budget might be. This has to take into account the interactive risk between the two types of commissioning, populations and the provider's ability to absorb the risk at the same time. This is why working together to solve the problems in our ICP, from a pathway perspective, is so important. Because of the CCG funding allocations, our population does not have the money the national formula believes it will need to meet their needs. Add this to the specialised commissioning risk I have described and you can see why we need to change at a reasonable pace. I am pleased that this year's tariff proposals recognise this with only two additional blended payment proposals.
There is a huge opportunity for us to shift the dial on selfcare, prevention and wellbeing, but this needs to be done with partners, patients and future patients.
Along with recognising the specialised/local commissioning issues for trusts like UHS we also need to have a national discussion about how the capital needed for specialist transformation will be recognised and made available in a way that supports pathway configurations at a level greater than ICS populations.
I am aware that regional and national specialised commissioners are working all of these issues through at the moment and I would urge them to engage with providers like ours, as well as fully specialist hospitals and those DGHs with some specialised services. This way we can work on delivering the long term plan solutions together.