Last month NHS England and NHS Improvement (NHS E/I) published plans for a new approach to assessing NHS transactions that put more emphasis on ensuring local populations benefit from NHS mergers.
Until recently, NHS transactions were overseen by NHS Improvement for organisational impacts (e.g. finance, organisational risk), and the Competition & Markets Authority (CMA) for competition. Most CMA reviews also included a wider assessment of the expected benefits for patients so that these could be weighed against any adverse effects arising from a loss of competition.
NHS trusts going through the CMA process generally found the patient benefit focus helpful (even if the competition element felt arcane). As a result, NHS E/I plans to retain patient benefit assessments, as part of its own revamped transaction oversight process, now that CMA involvement is coming to an end. We certainly think this is a good idea, and it is something we have advocated before now.
The formal test that NHS E/I is planning to adopt is: Do the deliverable benefits to the population [from the transaction] materially outweigh the costs and risks in the medium to long term?
The detail of how NHS E/I administers this test will undoubtedly give rise to much debate, but the principle seems the right one. That is, NHS Trusts when deciding to merge (or engage in other similar transactions) should have a well articulated plan for how it will lead to improved services and benefit their local population.
So far, so good.
NHS E/I will, however, want to manage a couple of risks that could come from adopting this test.
- The first is a temptation to nod through transactions that have significant short-term costs based on a promise of medium- to long-term benefits that, in the end, don’t eventuate. NHS E/I can mitigate this risk by: (i) evaluating expected benefits with rigour, making sure they are grounded in high quality evidence and robust implementation plans; and (ii) making sure that Trusts deliver tangible benefits in the short-term as well as the medium- and long-term. Our experience – having developed patient benefit cases with several Trusts and evaluated others – is that having a plan to deliver some benefits very soon after a merger plays an important role in gaining staff/patient/population buy-in.
- The second risk is that by linking NHS transactions more closely to service change, a significant number of NHS E/I decisions on these transactions could be subject to judicial review (JR) by those opposed to planned service reconfiguration. Service reconfiguration tends to be controversial, and there will frequently be some level of objection. Well-constructed patient benefit cases will, however, mitigate the risk of a successful JR. (This was seen in Bournemouth-Poole where the patient benefits case helped stave off a JR challenge to planned service reconfiguration.)
Neither of these risks are sufficient though, in our view, to not adopt the proposed new test for assessing NHS mergers.
Our work helping both Central Manchester / University Hospital of South Manchester and Bournemouth / Poole formulate benefit cases has shown to us how helpful these cases can be in terms of not only identifying and planning for service improvements, but also in terms of bringing together stakeholders to support significant organisational change.
If you would like a conversation about constructing a patient/population benefit case, then please feel free to get in touch.