Population based mergers – a new way of thinking?

Categories: Leadership.

Hospice UK CEO Tracey Bleakley writes about the benefits of collaboration and mergers across the health and social care sectors.

It has always struck me as odd that businesses think of mergers as a way of increasing their market share, attracting more customers and growing the business, whereas charities tend to think of mergers as a last resort to avoid downsizing and insolvency.  In the UK we have a vibrant third sector and we encourage new charities to form with new ideas and a passion for the cause they are trying to help.  The very qualities that charities need to succeed – single minded determination, passion, a vision to change the status quo and a distinct culture can work against the idea of collaboration and merger when charities become more mature.

In health and social care we can also see examples of merger and consolidation across the UK, from health and social care boards to CCGs, as organisations try to do more with less and make every pound go further.  At the same time, the Health and Social Care Act of 2012 encourages competition rather than collaboration.  For hospices, as both charities and bidders for NHS contracts, these are confusing times.

Experience has taught me that the worst time to consider a merger is when a charity is struggling to make ends meet, and so if a charity is heading in that direction an early merger will achieve a better outcome.  Mergers involve a significant investment in time and money and a certain amount of risk.  It is difficult to create the space to drive a successful merger when every second of every day is focused on keeping the charity going, keeping the cash flow balanced and staying solvent.  A poor financial prognosis and an ailing balance sheet will also limit the pool of potential suitors, and a merger between two struggling charities could exacerbate rather than relieve the problems.  At this point far more creative and radical options are needed, at a time when senior management teams and boards are likely to be exhausted and demoralised.

So what is the answer?  We are in an era of population based healthcare approaches.  It is no longer enough to say that our inpatient units are full to reasonable capacity and our community teams are working flat out.  It is now about understanding the need in the area we are here to serve, how many people we are missing every year and how we can help everyone who needs us.  We cannot do that alone.  It is going to take collaboration between hospitals, within health and social care and with other charities and community groups.

Consider your local area.  If you were setting up a hospice (or a palliative care service) now, what would it look like? Do you need inpatient beds and if so, where would you locate them?  Where are the gaps in provision?  Do existing services still work as well as they could?  Are too many individual services helping the same group of people?  How are things likely to change over the next five years? And the next ten? We have been doing this exercise in many of the Hospice UK roadshows this year using the new Hospice UK PopNat tool, and the consistent theme is – it would not look like it does today.

Once you understand what your current and future population needs are, you can start thinking about how to get there.  Here is a radical question – does your town or city or region really need more than one hospice organisation?  The answer may be yes, but it is important to know why.

Looking at this another way, what might a family faced with a terminal illness for the first time expect from a hospice service (assuming they know a hospice is not just a place to die…)  They might reasonably expect all the hospices in their area to offer broadly the same services and for specialisms to be clear and understood.  So two families living half a mile from each other could expect the same level of service and quality, but the one facing MND might be referred to a different hospice in the area because they have specialist day and respite services on offer.  This takes collaboration and a willingness to compromise.  Commissioners might then expect these services to be offered at the same price – is that achievable?  The North East hospices are working towards this goal within a collaboration that started out looking at coordinated education across the region.

Families might also expect to be signposted to other local services they need (or even better, for these to be coordinated centrally).  This would involve charities such as Citizens Advice, Relate, and MIND as well as a host of local charities and programmes.  Do you currently share this information across local hospices?  One hospice has joined a local partnership of complimentary charities in their local area.  Now one of the CEOs has announced their retirement, they are moving towards a more formal governance structure rather than replacing the role.

Management roles are expensive and in some areas it is not possible to recruit HR, Finance, Fundraising, Clinical Directors and CEOs for every hospice.  Even without a merger, can roles be shared?  If not, we risk driving up recruitment and salary costs as we chase the same small pool of talent and the hospices with vacant roles will start to suffer and decline.

Data is another key area.  Many hospices are now on the same systems as their local GPs and acute hospitals.  If hospices are to agree common tariffs and quality standards then this will involve some data sharing.  The Greater Manchester hospices have recently agreed to joint-fund a data analyst and it will be interesting to see how this work develops.  Can we go further in sharing advance care plans?  Coordinate My Care is a system which is aiming to do just that across London, allowing patients and families to create their own account from home and change their wishes and preferences as their condition progresses.

Hospices have often been slow to embrace new technology as they rarely have the funds to employ IT Directors or create ambitious technology strategies.  By working together hospices could increase their buying power and their ambition.  We are already seeing how virtual reality headsets can help patients at the end of life revisit their favourite places without leaving a hospice bed and how Project ECHO can transform local collaboration and learning.  Technology could have a huge impact on workforce, cost and quality of delivery and patient experience but we will need to work together to achieve this.

What other partnerships and structures and agreements could be created in your area to help reach more people in need?  Can your hospice take a greater leadership approach locally, not just in palliative care, but also in new approaches to delivering health and social care more broadly?

It is interesting that the gut reaction to collaboration and charity mergers is often loss and grief. It can feel like an ending.  We need to start looking at this in a different way.  Mergers and collaborations are a beginning, the sort of disruption one would expect from a vibrant hospice movement.  For those who will no longer be involved in the new regime, they will have helped create a legacy and a new generation of hospice care for the future.  It is time to be bold and create an exciting new future where everyone at the end of life can access the care and support that they need.

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