NHS merger activity has increased markedly in the past 12 months. The Competition & Markets Authority (CMA) has just cleared major transactions in Manchester and Birmingham, and further NHS mergers are planned in Essex, Gloucestershire, Dorset, and elsewhere.
Everyone in the NHS knows that while mergers can provide opportunities for significant service improvements, they also carry major risks. For every Western Sussex, whose recent success has been built off the merger of Royal West Sussex and Worthing & Southlands Hospitals, there is a South London Healthcare, Barts Health or Heart of England, where a merger has been a major contributor to underperformance.
With the large number of transactions in the pipeline, and the financial pressures facing the NHS, it is more important than ever that NHS mergers succeed in improving services and realising efficiencies.
The NHS merger approval process has an important role in maximising each merger’s chances of success.
At the moment, NHS mergers must go through an NHS Improvement (NHSI) review process, and for those mergers that raise issues of patient choice and competition, there is also a CMA review process.
NHSI reviews the business case for a merger, which focuses on the strategic and financial case for the merger, setting out the impact on clinical services, workforce, and other areas, such as IM&T, and plans for delivering post-merger integration. A CMA review, where needed, involves a competition assessment, and may also include a patient benefits case to show that these benefits outweigh any concerns arising from a loss of patient choice.
A merger business case differs from a patient benefits case in the breadth of its scope. For example, it is concerned with organisational and workforce impacts, not just patient impacts. Its greater breadth also means that, necessarily, it is less detailed in its focus.
A patient benefits case, on the other hand, focuses on which services are going to change as a result of the merger (and could not be expected without the merger), how these changes will benefit patients, the number of patients that will benefit, and implementation planning for these changes.
In Manchester, for example, one part of the patient benefits case was cardiology services. The patient benefits case set out how these services would be centralised, why the merger was needed to bring about this change, how the patient pathway would change, estimates of of the number of patients benefitting from reduced time to treatment, reduced length of stay, reduced patient mortality and reduced complication rates, the scale of each benefit (e.g. how long average time to treatment would be reduced), and detailed implementation plans for bringing these changes about.
There is, I believe, an important role for both the business case and the patient benefits case in planning NHS mergers. The business case addresses the big picture, while the patient benefits case sets out specific plans for service improvement following a merger.
However, under current arrangements, only the business case is routinely required. A patient benefits case is only prepared when competition concerns arise. Unfortunately, however, the lack of a patient benefits case lets merging Trusts avoid difficult conversations about service improvement.
On the other hand, where a patient benefits case is required, kicking the can down the road is not an option. The level of detail required by a patient benefits case is a trigger for serious conversations between clinicians, service managers and executives at merging Trusts. Issues around service delivery have to be thrashed out, and the implications for how individuals work in delivering newly redesigned services, such as rotas and service delivery locations, have to be confronted.
Avoiding these issues may make for an easier transaction, but if the management of a newly merged Trust keeps avoiding difficult issues of service reconfiguration and redesign, the opportunities brought about by the merger will be lost.
On the other hand, requiring a patient benefits case, as an integral part of the merger review and approval process (not just when there are patient choice concerns), will make sure the challenges, and opportunities, of service redesign are identified and confronted, as a condition of a merger taking place. A detailed plan of service change and improvement, against which the merged Trust can be held accountable, will be in place before the merger.
This will surely make for better NHS transactions, and better outcomes for patients.