Whatever the eventual problems, all of the TCs in our sample had, more or less explicitly, a group of enthusiasts, mainly the ‘idealists’ (see Chapter Three), who generated the momentum and the energy to try to bring about innovations and improvements in care in the TCs. For them, the tumult of national policy changes and failing local business models was background noise as they strove to introduce practice innovations for their own TC, invariably meeting local resistance from one source or another even when other sites might regard the change as unexceptionable. This chapter examines those innovations in care, including changes in both the structure, such as transformations in the physical environment and in staffing, and the process of care, such as the application of new clinical pathways.

Achieving targets: structure, process and outcome?

Despite the mixed motives for the innovation and all the difficulties that emerged once they were running, most of our case study TCs increased the throughput of patients and all were thought by the wider health economy to be important contributors to achieving not only waiting list targets, but also providing greater patient choice. For example, Ruckworth, for all its difficulties, was nevertheless helping its partner trusts to meet the government's stringent waiting list targets. As our fieldwork was ending, an option appraisal there, which included the suggestion that the unit be closed down, concluded that the TC should be kept open, and a number of suggestions were made to help limit (and share) the continuing financial losses. This was based on the view that over the coming two or three years there would still be a need for at least some of the beds to remain open in order to continue to meet those targets. Even St Urban’s, which was eventually forced to close, was able to capitalise on its unused facilities to make a significant contribution to meeting its host hospital's waiting list targets. Ironically this was not due to its different ways of working; the average length of stay of patients going through the TC was no different from the rest of the hospital.