Background to the development of SCNs

NHS England's (NHS-E) statement of its intentions to host and support SCNs started by observing1 that: “Clinical networks are an NHS success story…networks perform varied and valuable roles…” A recently published book,6 which assesses the development of managed clinical networks to date, concludes that while the record is perhaps rather more mixed, nevertheless, clinical networks “should be given more time to develop and reach their potential”. Networks can make effective use of scarce resources, bridge the cracks between services offered by ‘self-interested’ NHS organisations, and move knowledge around clinical communities more effectively than hierarchy and the market.

1996 was a key year for the idea of networks. A review7 argued that there have always been networks in the NHS but ‘ad hoc’ and ‘hidden’. Sir Kenneth Calman, reporting on his review of cancer services, recommended the creation of cancer networks, with points of service differentiated by the degree of concentration of specialist resources—centres, units, other services.8 Then, in 1998, Sir David Carter (reviewing acute services in Scotland) formulated the general idea of a ‘managed clinical network’, neither hub and spoke, nor a loose association.9 Sir Ian Kennedy's latest review10 sets out the importance of networks as follows: “In successful networks of care built around specialist children's hospitals, children will receive the best possible quality of care as close to where they live as possible. Without successful networks, children might receive inappropriate or poorer-quality treatment locally, or else may be required to travel long distances, receiving treatment in specialist centres that could just as easily take place in their local hospital.”

More than 15 years from the recognition of networks as a legitimate principle in organising health-care, the variety of forms that networks can take—voluntary and mandated, formal and informal, vertical and lateral—is better understood.11 ,12 A recent review of experience in Scotland13 concluded that “Clinical networks are always a work in progress, because they are a response to problems of co-ordination across complex organisational and professional boundaries. Such problems cannot be definitively solved, but clinical networks are a means to flexibly address and improve them.”

Following a national review of clinical networks of all types, the NHS Commissioning Board published its proposals14 for networks in the modernised NHS in February 2012, emphasising the need for clear criteria in establishing networks, transparent process and clarity of purpose. Those established by the NHS Commissioning Board, now NHS-E, are called SCNs. Other delivery and professional networks will be established locally by commissioners and/or providers.

The creation of SCNs as ‘outposts’ of NHS-E within the new ‘regional’ structures of the NHS, where they sit close to the Clinical Senates provides a mechanism for further evolution of the idea.

Purpose of SCNs

The overarching purpose of the SCNs is to improve quality of care and reduce unwarranted variation. Described as ‘engines for change’,1 the first SCNs have been commissioned where an integrated whole-system approach is required to achieve real change. CYP, particularly with complex needs, require many services which must work effectively together in order to provide integrated care around the child.15 SCNs can progress integrated care not only across health service organisational boundaries, but also by working with partner agencies such as Social Care. Their line of accountability is to NHS-E through the Local Area Teams (LAT). The Maternity and Children's SCN has been most closely aligned to Domain 3 (Recovery from Injury and Illness) in the NHS Outcomes framework.16 All SCNs are also expected to deliver improvements in Domains 4 and 5 (Patient Experience and Safety). Led by a clinical director and network manager, SCNs will consult with key stakeholders including the public and patients, Clinical Commissioning Groups, LATs and providers on a strategic plan which will be signed off by the LAT's director. Other key relationships will include Clinical Senates, Academic Health Science Networks, Clinical Research Networks and Local Education and Training Boards.

“No decision about me without me”17—the voice of children, young people and their families is key to making services right for patients.18 The Children's commissioner has just reported19 on the participation of CYP in strategic decision making about health services. SCNs can ensure that mechanisms for patient engagement for all ages influence service improvement plans. Strong links will be developed with the Health and Wellbeing Boards and third-sector organisations.

The SCNs will have a role in recognising, and overseeing, the Operational Delivery Networks,20 such as Newborn Services, but will have no means of funding existing or emerging networks. Each delivery network will be hosted by a service provider with a subscription to network members for administrative costs. Innovative approaches to hosting arrangements will be required, such as the model provided by Partners in Paediatrics21 ,22 in the West Midlands where a number of networks can be hosted on behalf of the local trusts within one organisation.

The SCNs will provide clinical leadership and expertise in building and overseeing network arrangements so that the commissioners can support pathways of care. At their most developed, these could extend from primary and community care to tertiary and quaternary services. Providers will know what care they are designated to provide, the quality that is expected and when the patient should be moved along the pathway. Local or network guidelines which digest and use National Institute for Health and Care Excellence (NICE) and other evidence based guidance will ensure consistently high-quality care, appropriately located.

Challenges to success

First, a clear vision is important, but it must be ‘tangible’. Experience suggests that work on specific projects that address affiliate members’ interests is crucial. Early success is required to demonstrate network potential.11 ,13 This is particularly important as there is a real risk that clinicians may not engage with SCNs due to competing clinical and time pressures. The new structures in England require clinician engagement in multiple new bodies, and inevitably this will impact disproportionately on a small number of clinicians in leadership positions.23

SCNs are ‘mandated’ with a centrally funded network core, they are potentially time-limited, non-statutory bodies, and membership is voluntary in principle. Recognition of the network and its right to pursue its interests will not emerge automatically, simply as a result of the SCN's designation. Clinical networks have to make sense to many different stakeholders and this is especially the case for the SCNs which are required to develop collaborations over large geographical areas and to align very new commissioning organisations and very varied provider organisations.

Their relationship with commissioners will be crucial, but they are neither directly responsible, nor accountable for commissioning services. They are intended to work through processes of influence and intelligence rather than direct authority. Although powers to recognise and support operational delivery networks will provide some bite, this mix of characteristics means there will be substantial challenges. These include the market and rules about tendering services, and the politics of service location. Ensuring proper attention to services for CYP still remains an issue as many of their affiliate organisations will not have CYP as their exclusive, or even primary, concern. Even if the institutional context for networks has never been more favourable, delivering improvements will take time that this first wave of SCNs may not have.

Clinical networks need credible and influential leaders. Not just single individuals, but several clinicians and managers forming a core team is more effective in carrying the work of engaging multiple stakeholders across organisational and professional boundaries and more stable in the face of changing personnel.13 Network management requires specific skills and approaches, those of relationship-maintenance, diplomacy, consultation and negotiation.11 And there are choices to make about retention of existing networks judged to be able to perform effectively or the development of new networks.

Knowledge is a key resource—the tools of guidelines, care pathways, designation, peer review and audit will help affiliates to learn about service improvement together. SCNs are well placed to promote a consistent approach to data collection and analysis across England. Variation in outcomes from different providers3 can then be used by networks working with local and national commissioners, service planners and public health organisations to shape the services appropriately.

The role of the Royal College of Paediatrics and Child Health (RCPCH)

Working in teams and across clinical boundaries comes naturally to many paediatricians and so, working within a clinical network is already a reality for many. In 2012, the RCPCH published a guide to implementing clinical networks entitled ‘Bringing Networks to life’.12 The purpose of the document was to show clinicians how to get involved in a variety of clinical networks, to demonstrate the strengths and challenges, and to share good practice from established networks.

It is a prime objective of the RCPCH to work in partnership with the SCNs, NHS-E, the CYP's Health Outcomes Forum and other key stakeholders to ensure that outcomes and recommendations in the CYP's Health Outcomes Forum report, and standards set by the RCPCH are met. Examples are the Facing the Future Standards which consist of a set of 10 service standards for acute paediatric care.24 An audit of the standards has recently been published.25 The RCPCH and other partners can also support the SCNs through the development of other clinical standards and best practice patient pathways.

The 12 Maternity and Children's SCNs need to collaborate to maximise their impact on national issues, such as child mortality and morbidity, workforce and reconfiguration of services. The RCPCH is in an excellent position to facilitate these discussions.

The RCPCH has a strong advocacy role and will be able to facilitate links between the SCNs and the RCPCH patients and CYP participant groups.18 ,26

By using RCPCH workforce data27 ,28 SCNs can provide the necessary evidence to influence Health Education England and the Local Education and Training Boards to develop best workforce models so that the right numbers and types of paediatricians are employed and that the right numbers and types of trainees are trained. Furthermore, the RCPCH can support its members in developing leadership skills.

The way forward

SCNs are engines for change across complex systems of care; as such, they provide immense opportunity to improve quality of care for children and families. This requires major changes to the way care is delivered. The SCN teams can provide energy, innovation, intelligence, leadership and ‘buy in’ from commissioners, but strong support and cooperation is needed from those on the front line if SCNs are to succeed.