The role of hospitals in community based healthcare
Paul Tunnah interviews Dr Gareth Goodier
University Hospitals NHS Foundation Trust
Financial pressures owing to the current global economic climate spell out change for the way healthcare operates in many countries, but none more so currently then the expected realignment of the UK’s NHS. The government’s recent White Paper paints a picture of increased focus on care in the community, with the hope of concomitant savings and a better process for patients.
However, these changes will not only have an impact on how the pharma industry engages with healthcare providers, but also spell out a new role for the secondary care centres, including the many major hospital groups that are at the core of specialist patient care and cutting edge research. What role will there be for such centres in the brave new world and what does this mean for pharma?
In this interview, pharmaphorum spoke to Dr Gareth Goodier, the CEO of Cambridge University Hospitals Foundation Trust, to hear his views on what changes we could see coming up. Dr Goodier is familiar with healthcare systems throughout the world based on his international experience and today faces the challenge of managing leading research hospitals such as Addenbrooke’s. Here he explains what a more community based healthcare system really means for healthcare providers, pharma and the patients.
Interview summary
PT: Hello Gareth. How did you find your way into this role?
GG: I qualified as a medical practitioner in 1974, working as a clinician in the UK, Saudi Arabia and Australia before moving into management positions. I’ve been in Chief Executive or similar roles for about 20 years now and been the CEO of four academic organizations - the Royal Brompton and Harefield, Royal Perth Hospital (Australia), the Women’s and Children’s Hospitals in Perth (Australia) and Cambridge University Hospitals as well as the North West London SHA.
PT: What does managing such a major hospital group involve?
GG: A lot of hard work and long days! Approximately 70% of the time, is spent managing internal affairs and 30% is spent on external issues, working with the local partners like the PCTs [Primary Care Trusts], PCT providers, other District General Hospitals, universities and so on. Also, the Chief Executives of the senior hospitals in the country typically get involved in national leadership roles. My two are developing policy areas such as medical education and research, so it’s very varied with hardly ever two days the same.
PT: How does your experience abroad compare to the UK?
GG: The Australian health system is very similar to the UK from a patients’ perspective, except Australia has about 30% private practice, so it’s a bit easier to go around the government if you want to. The role of a CEO is similar here and in Australia - there’s an element of having to find a 3–5% efficiency dividend every year and there’s always politics involved one way or the other!
PT: And Addenbrooke’s is also a teaching hospital. How many teaching hospitals are there in the UK in total and what does this mean for you in terms of operations?
GG: There are 45 to 50 teaching hospitals, but I make a very strong distinction between teaching hospitals where the emphasis is on teaching health professionals and the 10 to 15 academic teaching hospitals where there is research as well. Cambridge University Hospitals, which includes Addenbrooke’s and The Rosie (our maternity hospital), is one of five comprehensive academic health science centres.
"...the registrars we have are much less experienced than they used to be and that’s becoming a bit of a worry."
PT: How have you seen the process change for academic research over your time?
GG: It’s changed radically, there are now healthcare assistants doing functions that I did as a junior doctor in the 70s, with more senior specialist nurses running clinics and doing roles that junior doctors used to do. But the training of doctors has been significantly changed in this country over maybe the last five to ten years. We’ve created a lot of consultants very quickly and have done away with the senior registrar position in their training programme. That means the registrars we have are much less experienced than they used to be and that’s becoming a bit of a worry. The next stage is to have consultants delivering healthcare in areas like intensive care, critical care, accident and emergency and doing a 12 hour shift.
PT: Clinical research is an area that pharma tends to be heavily involved with, so how have you worked with the industry in this aspect?
GG: The UK has lost global market share in terms of phase III clinical trials, but the pharma industry goes directly to the leading researchers, it doesn’t really talk to the hospital management. So through conversations in the last couple of years I have been trying to get a more collaborative and tripartite approach to make sure that adequate resource is placed in pharmacy, imaging, laboratory and so on. However, the other emphasis has been on improving our performance in hospitals and networks, particularly around the bureaucracy of research. I’ve been chairing a group called the External Reference Group for the National Institute of Health Research (NIHR), which has been looking at all the standard operating procedures used by R&,D offices. A lot of effort has been put into reducing that process of approval to get a trial started and in Cambridge we’ve got that down to 30 days. Feedback from companies like Novartis is that those improvements can be detected, so they’re starting to invest more in the UK health systems.
PT: What kind of interaction do you personally have with the pharma industry?
GG: Sally Davies, who heads the NIHR, has a leadership forum called the NIHR NHS Biopharma Leadership Forum. I’m on that, with about five other Chief Executives, a few of Sally Davies’ staff, and some leaders from the biopharma industry - typically Medical Directors. We meet every three to four months to talk about ways of improving this engagement and the feedback both ways has been useful. But in 20 years as a CEO I haven’t been approached by a pharma company directly, other than one approach from Merck about a PET-CT facility. So we don’t have a constructive relationship between the pharma industry and hospital management and that’s been a core failing. Both sides recognise the need to improve if we are to keep our name for quality and performance.
"Feedback from companies like Novartis is that those improvements can be detected, so they’re starting to invest more in the UK systems."
PT: So where do you see the UK’s future?
GG: I’m optimistic. Medicine in this country is still delivered at a very high quality and for a good price. We were poor in the management of the bureaucracy of trials and probably have interpreted some of the European legislation more strictly than most other countries. The legislation was about quality and it’s evident that the work done in the last year or two has improved our performance and shown that we can rise to the challenge. Again, the feedback from Novartis was that, apart from showing that our bureaucracy has improved tremendously, analysis of the full cost in the UK found that we are competitive. If we focus upon the support structures around the trials then we will win back market share.
PT: There are a number of joint working initiatives in primary care where the pharma industry is collaborating with GP groups. Are you seeing such initiatives within secondary care?
GG: I don’t see it at the moment, but there is more dialogue and collaboration working towards an integrated health economy at the moment than I’ve ever seen anywhere in the world. Around Cambridgeshire we have had direct talks with GP clusters and we have a CEOs group, which includes the PCT and the PCT provider, plus the District General Hospitals around us. Our aim is to establish a health economy for which there is an integrated hub and spoke model for service, education and research. This will lead to much greater opportunities with the pharma industry on trials, particularly for the more significant phase III work.
PT: Obviously, there are fairly significant changes coming through because of the move away from PCTs and towards GP consortia. How do you see that impacting on your work?
GG: It really affects us in long term conditions, diagnostics and particularly in care of the elderly. A year ago we set up, jointly with the PCT, a clinical group where we identified nine streams of work. A lead consultant from the hospital and a lead GP from the community worked together to come up with the best pathway to drive patient care, to move as much care as possible out into the community. This is based upon a model that we’ve developed out of Addenbrooke’s, in diabetes, where the care is not delivered by doctors but by specialist diabetic nurses. When that nurse needs help, from a clinical governance point of view, he or she would go to the community diabetologist rather than to the GP. It’s critical that the nurse keeps the GP informed of everything, but we’ve demonstrated that you can keep the patients healthier, keep them out of hospital more and save the whole health economy money. We’re now trying to take that model out into the community in different clinical areas, in addition to working on pilots to move some of our imaging and pathology to the community (as it is in Australia). The main change we will see is diagnostic workup in the community and hospital outpatients will shrink considerably. Also, you will see more and more specialists doing clinics out in community settings.
"The trend is quite clear - that more and more work will be conducted in the community."
PT: Are you confident that these changes will reduce the burden on secondary care?
GG: It will have a dramatic impact upon the way our hospitals are run if we follow what is currently being done in Australia. A patient in Australia who is given a form for a blood test or a CT by the GP will have 15 or 20 different sites they can go to in order to get the test done. The GP then gets the results that same day. That ready access to diagnostics in the community is the rate limiting step in this development here, but once that’s been done we should see a significant reduction in the number of patients who are referred to and seen by a registrar in a hospital setting.
PT: From the patient perspective how would you summarise that ideal mix of services provided by the different settings?
GG: The trend is quite clear - that more and more work will be conducted in the community. The question is therefore what is the role is of a District General Hospital? For many of the smaller ones they might become ambulatory care centres with a full range of diagnostics, mainly outpatients, day treatment, day surgery and maybe some beds for elderly care. The more complex care has to be aggregated, because if you’re going to have a consultant delivered service at night you won’t be able to do that in small hospitals. So you’re starting to see more distinction between the really complex care, which has to be managed in places like Addenbrooke’s, and care of routine outpatients at ambulatory care centres.
PT: How else do you see the NHS evolving over the next 10 years or so?
GG: We’re about to enter a period of immense change and it’s going to be a challenge for the GP consortia to manage the commissioning. I do fear for the academic and major hospitals in this country. What most people don’t understand is that we receive the same tariff for a diagnosis as a small District General Hospital does. The changes that need to be brought in are that there needs to be an adoption of a more granular HRG classification system, more akin to either the Scandinavian DRG or the Australian DRG system, and also some consideration of a premium for the academic centres. These centres look after the more complex patients and no matter how granular your classification system there are still costs that are never recognised by such a crude methodology. If I was Secretary of State I would be considering more of a Dutch system, which has a greater consumer approval rating. The question is whether all the change is going to be worth it in five or seven year’s time, or whether you could have used the opportunity as a change to adopt a slightly different system.
PT: Gareth, it’s been great to hear your perspective, so thank you very much for your time.
About the interviewee:
Dr Gareth Goodier qualified as a medical practitioner in 1974 and has practiced as a clinician in the UK, in Saudi Arabia and Australia before moving into management positions. He has been a Chief Executive or in a similar role for the past 20 years. In particular he has been the CEO of a number of academic organisations in the UK including Royal Brompton, Harefield, North West London SHA and was appointed as the CEO of Cambridge University Hospitals NHS Foundation Trust in September 2006. He has also worked in the private sector as a consultant for Arthur Anderson and for the World Bank.
How will the NHS evolve in the next ten years?
