Board sign off of Annual Plan, Report, Quality Report and Accounts

It is that time of year – an extra Board meeting to sign off these important documents. Overall we broke even last year, though the accounts show a deficit due to estate revaluation. The Annual Plan requires a three year view – not easy! After last winter ward closures feel unrealistic. More likely, we believe, is the steady ‘conversion’ of in-patient capacity to home care capacity. A complex subject worthy of exploring another time

The Annual Plan will be available on the Monitor website, and Trust Annual and Quality Reports on our own website in due course

Interview for Solihull MD

Our Trust covers three distinct communities, so I delegate some of my CEO responsibilities to two Managing Directors. These cover Good Hope Hospital in Sutton Coldfield, and Solihull Hospital and Community Services, and my Solihull MD is leaving to take up a CEO post in Cumbria (good luck Claire!) Disappointingly we did not make an appointment, but one thing I have learned is to wait until the absolutely right appointee appears

This is a great opportunity for the right person to forge ahead with the creation of an integrated system and a strong future for much valued small acute hospital. I will advertise again in a few weeks – the right person is out there I’m sure!

Risk Summit

A follow up to the April summit, and a searching but positive meeting. Our Emergency Care Action Plan, agreed with Monitor, is on track and performance is much better. We achieved 95% in May, and more actions are to come. Internally, maintaining operational consistency is essential. Externally, capacity to allow timely discharge is crucial, and remains our main risk for next winter

An Urgent Care Board has been established to provide system leadership. This is a hugely important forum in terms of addressing what is now recognized as a complex and multifactorial challenge

Health and social media conference

A great day with over 60 social media and health enthusiasts! Engagement levels were high and the hashtag #NHSGoSocial was really humming. I spoke about my experiences as a ‘user’ of social media; @VivionCox, CEO of @klood_com covered the technical aspects and demonstrated the ‘Klood engine’ that will measure impact, authority and reach; and Ben Pathe (@BenP1972) of @PatientOpinion showed us how social media is transforming feedback from patients. @Gemma_Finnegan and Michael Seres (@mjseres) of #nhssm gave some really helpful insights to finish the day

Three blogs from Andrew Hughes (@meantality), Highland Marketing (@HighlandMarktng) and Patrick Keady (@QualityRiskMgt) give a flavour of the day. Grateful thanks to Klood for hosting us!

Pre-degree care experience for nurses

It is a privilege to be asked to join this group, established to work up the pilots for this recommendation from the Francis Report, and the subsequent action from the Secretary of State. My understanding is that few individuals without some sort of direct care experience are currently accepted for undergraduate nursing courses, but standardising this must be good for both public reassurance and reduction of drop out rates from the undergraduate degree programme

I am there to give an ‘employer’ view, but it is also useful learning for me – implementing plans on a national scale is one challenge I don’t usually have!

NHS Confederation annual conference

Tweeting CEO's Rob Webster, Lisa Rodrigues, Dean Royles, and me!

I always enjoy the NHS Confederation conference. An opportunity to share experiences and ideas, get a sense of what is happening across the service, hear the ‘messages’ and ‘direction of travel’ first hand – and to be inspired

Sir David Nicholson, in his last Confed speech as NHSE CEO, spoke with his customary passion. He talked of his formative years, of his pride in the improvements in care he has overseen, and he showed through his priorities for the coming year that he understands where the current gaps and challenges are. My role is a much smaller one, but I can appreciate the immense difficulties in setting a course and maintaining uniform standards across a highly complex system like the NHS. I can also empathise with the personal criticism he has endured – nowadays an inherent part of a senior leadership role in the service, and an aspect he commented on. Afterwards, the warm applause reflected that, on a human level, his contribution during more than 7 years in one of the most difficult jobs around was appreciated

Here is an early blog on the conference by Jonathon Fagge, a CCG Chief Executive from Norwich

I will finish with two quotes that I will keep in mind, both from a very good session on ‘Making integrated care happen’ that I contributed to as a panel member:

Barbara (Pointon), a carer, reminded us that any integration process must, above all, simplify current arrangements, because ‘care is care is care’

Peter (Hay), Director of Adult Social Care in Birmingham, asked a question of senior leaders – ‘are we investing enough of ourselves, and our time, in relationships?’

A busy week, varied as always, combining management of the ‘here and now’ with forward planning as we finalise our Annual Plan for Monitor, and our Annual Report. It ended with reflection – at an academic seminar on ‘knowledge mobilisation’ amongst CEO’s. I will discuss that another time, but this weeks diary starts with an event from the end of the previous week…

Joint Conference on Compassionate Care

 

Our Trust and the Dying Matters Coalition jointly hosted this conference last friday (17 May), as part of the Dying Matters Awareness Week. The conference was chaired by Lord Philip Hunt, and our Chief Nurse Mandie Sunderland welcomed Jane Cummings, Chief Nursing Officer for England, and Eve Richardson, Chief Executive of the Dying Matters Coalition. You can view the programme here and a short video here

This is a hugely important area, and we will be working together for three years on a compassionate care training programme for all of our 6000 nurses, with the aim of providing the best possible care and support for people nearing the end of their lives.

We will also be developing an improved compassionate employment programme to support our staff

According to the research commissioned by Dying Matters, 63% of people in the West Midlands are comfortable talking about their end of life wishes, yet just 36% have made a will, around 10% have written down their funeral wishes, and just one on fifty has made an advanced care plan

The quality of the nursing care we provide is, judging by the conversations I have and the mail I receive, an enormously important area for people in our communities. This work, on compassionate and end of life care, is a fine example of the excellent work our nursing teams are engaged in, and I look forward to supporting the programme and seeing the improvements in care it will surely bring about

Partners meeting in Solihull

I met with the leaders of Solihull Borough Council, Birmingham and Solihull Mental Health Trust, and Solihull CCG on Monday to talk about our progress towards creating an integrated care system within the borough. We have laid strong foundations and have widespread buy-in, and with the imminent appointment of a new Executive lead for HEFT we are planning the next stages

The recently announced ‘pioneer’ programme may offer us support to progress this work more speedily, so we are preparing our application. 

As an NHS we seemed to have talked about ‘integrated care’ for years, but progress ‘in the field’ has been slow for a multitude of reasons. There seems to be a real will from the centre now, and I look forward to developing this exciting part of our organisation further

Patient Safety Congress, Birmingham 

I spoke at this conference on wednesday. It seemed a large and well-attended conference with a wide range of speakers and important topics on the agenda. I was speaking at a side event, for healthcare CEO’s, on the involvement of clinicians in setting safety strategy in hospitals

My three points:

1. what lies behind our overall mortality rates? Looking for peaks within an average rate overall gives useful pointers for action
2. using objective clinical standards to underpin clinical service reconfiguration
3. prioritising emergency care and improving ‘flow’ will improve safety, patient experience, and clinical outcomes

Emergency Care

Still our major operational concern. Things are improving steadily and we may achieve the 4hr target for May. A special mention for our Good Hope team who have done a sterling job this week, performing well despite the knock-on effects of the temporary closure of a neighbouring A&E, and moving the Acute Medical Unit into new accommodation and implementing new and improved processes

The ED consultants in our region have raised their concerns publicly. I fully understand their position, and will be responding with a joint letter from my Medical Director and myself. I will publish this in my next diary

Next week…

Follow up to the Risk Summit, and our conference on ‘Using social media in healthcare’ on friday!

The crisis in emergency care has now been acknowledged as a ‘system’ problem, rather than something caused by ‘poorly performing’ acute trusts. I am sure readers of this website have known this all along.

It is important this is recognised, so that the right solutions are considered. Of course, most hospitals could without doubt improve on their internal processes – specialty support to ED, effective daily ward rounds and early in the day discharge, early discharge planning, speedy diagnostic support, effective and knowledgeable management of ‘flow’, and more besides.

But, acute hospitals alone cannot fix this, not for long anyway. The problems run deeper, and the general population now has particular expectations of immediate care. A&E may not offer the best experience, especially when busy, but it does offer rapid assessment by a doctor, immediate diagnosis, and the dispensing of drugs and reassurance without having to make multiple phone calls and search out a late-opening chemist.

The crisis is not, barring a few exceptions, caused by increased attendances at A&E. Overall numbers are similar to last winter, and where they have risen it is largely due to ‘minors’. These add to the workload, but do not tend to materially affect throughput.

Our own analysis suggests the key difficulty is discharge. It isn’t the only pressure, but it is the pre-eminent one. We can accurately predict tomorrow’s performance from today’s discharge numbers. Adequate discharge numbers mean the next day starts with available capacity, and the daily workload and ‘flow’ will nearly always be managed well and smoothly, with obvious benefits to patients.

The discharge process slowed over last winter. Official ‘delayed transfers of care’ did not rise, but the duration of the (laborious) assessment process was longer. And our repeated point prevalence audits showed significant numbers of patients waiting for community health capacity to become available. It seems clear that our community healthcare providers lack sufficient capacity, and on ‘block contract’ arrangements they cannot over perform.

There are no queues in community healthcare, social care, or primary care. When the system reaches gridlock, their queues are situated in our beds, on our wards. The visible queue then forms in ED, or outside as the ambulances start waiting. These queues are what our surgical colleagues might call a ‘false localising’ sign.

One might say these pressures have always been present, but it doesn’t take a huge change to tip a system that always runs ‘hot’, with very high bed occupancy, into crisis.

Solutions? We have a full and detailed action plan, with three broad groups of steps we are taking:

- Internal actions. All those listed above, together with an investment in ‘supervisory ward sisters’. These ward leaders are not ‘in the numbers’ and are therefore free to manage quality, staffing rotas and sickness, and arrange early in the day discharges. We are also implementing electronic white boards (‘Jonah’) so we can track patients and properly manage capacity

- Collaborative work with partner organisations. ‘Trusted’ assessment with community health and social care, to avoid duplication and speed up this arduous process. There are other avenues to explore too – is there an alternative to housing community ‘queues’ in the most expensive part of the service? And then there is primary care, including urgent care/walk-in centres. How could they work differently to offer alternatives to attending the local ED?

- Additional capacity. We have very little of this in our hospitals, but as we are housing significant numbers of patients at any one time who could be better managed at home with support, or in an intermediate care bed, we feel we should purchase these ourselves. We already run some ‘virtual wards’ offering post-discharge support and we will enlarge this capacity significantly. We are also  exploring a link with a specialist in assisted living for those patients unable to manage in their own homes.

A final thought. At a recent international conference I learned that the UK now has fewer in-patient beds per head of population than European countries, North America, and Australia. Have we reached our limit in terms of bed reductions?

It’s great to see Dean Royles and NHS Employers highlighting the benefits of social media use in the NHS. Social media enables conversations, crosses organisational boundaries with ease, and spreads learning and innovation quickly and effectively

I have written before about why I use it. For me it is about driving openness and transparency in NHS leadership. As a hospital CEO I have many difficult and sensitive decisions to make, and I try to make them based on what is best for the patient. I have no other agenda, so why not share my thinking and encourage debate?

The hashtag #NHSEngage is appropriate because actually we aren’t too good at this! As the slide below (from a recent talk) shows, we tend to try and engage when we need something from our public. We must instead enter into a continual dialogue, and thereby build mutual understanding, and trust

Engaging with colleagues is educational, fun, and illuminating. In the slide below, on the right, CEO colleagues in mental and community health are discussing common issues. On the left, a member of our nursing staff, not known personally to me, responds to something I published in my blog. Isn’t it great, and positive?

Of course, any member of the public can engage, and they may be critical or challenging. I know this deters some colleagues, but why? The informal nature of the medium can help the conversation and, anyway, since when was not hearing, or not engaging, with complainants an effective or appropriate strategy?

And complaints are always balanced by compliments, such as this one from a colleague

And ‘anyone’ can include our journalist colleagues too, of course!

It’s a rich debate, that opens opportunities. Our recent leadership and management learning set for junior doctors came about as a result of a Twitter conversation – our younger colleagues certainly ‘get it’ and will offer us much if we engage with them on their terms

I am often asked how I link with our Trust Communications function. We work in tandem, sometimes overlapping and supporting, but with separate aims:

Our Trust Twitter account @heartofengland is run by Comms – have a look and you will see they major on information giving, highlighting events and activities, and delivering messages. 

My account @drmarknewbold is run by me – I do not have a separate personal account. As I am trying to personalise NHS leadership, a little of myself seems appropriate? Too much Leicester City talk would probably deter those who follow me because of an interest in healthcare, but an occasional comment should not, and it is part of who I am (although too much Leicester City talk would deter my real life friends too!)

I write a blog, which works well in conjunction with both Twitter and Linked In. Have a look here if you are interested. The most popular section is my CEO Diary, which I publish every couple of weeks. Again it is an attempt to ‘open up’ my professional role, and to share the breadth of issues that arise during my working week

It is a commonly held view that the NHS hierarchy is rather wary of openness and speaking out. I think this is changing, but is it risky to use social media? I haven’t found it so, although one must always remember that the serious and sensitive nature of our work applies to social media in the same way that it does to speaking or writing elsewhere. As more NHS leaders engage with social media so attitudes will change and, in the process, we will start to build a more open and transparent culture across the service

A brilliant example of how social media is changing the way we engage with patients and the public is Patient Opinion. We can engage with our public through them – look at this for a fantastic example of how open dialogue can change things for the better!

I strongly support the permissive use of social media in the NHS, and I wish #NHSEngage every success. Lets get behind it, and make it a consistent part of ‘how we do business’!

]]> http://www.marknewbold.com/index.php/2013/05/20/nhsengage-social-media/feed/ 8 http://www.marknewbold.com/index.php/2013/05/19/health-blog-round-up/ http://www.marknewbold.com/index.php/2013/05/19/health-blog-round-up/#comments Sun, 19 May 2013 18:04:09 +0000 MarkN http://www.marknewbold.com/?p=1272  

This is a new venture! The picture below is the top of our new ‘health blog round-up’ – to visit it just click here

The healthcare blogosphere is a very active one, covering the whole spectrum of opinion. Contributors range from professional writers and commentators through to front line NHS staff writing openly about their experiences at the ‘sharp end’

In this Scoop It site, Emily and I have gathered together a range of blogs we enjoy reading, with the aim of providing a starting point for interested readers

We would also love to promote blogs, particularly if you are new to writing and would like to increase your audience. Whatever your angle, please let Emily or me know if you would like your blog ‘scooped’ for our site and we will try to support

There is no editorial line. If it is well written, thought-provoking, relevant and interesting then we will highlight! 

Do let us know what you think. To follow, either bookmark and visit when you wish, or subscribe via the ‘follow’ button on the page

Enjoy!

A busy and varied week, with a serious message at the end

Patient Opinion

Regular readers will know I am a fan of the great work being done by the Patient Opinion team. If you want to see just how effective it can be, have a look here

My congratulations to Simon Jarvis, our Head of Patient Engagement, for his response, and for winning the accolade of ‘PO Hero’!

Urgent Care Summit

A meeting for commissioners and providers in Birmingham and Black Country, on Monday evening. The emergency care pressures are steadily easing, but not as quickly as in previous years. Now that NHS England has written out it seems to have finally been acknowledged as a systemwide problem, rather than one caused by the poor performance of individual Trusts. This is welcome, and helpful, because without first understanding the complex nature of the challenge, we will only resolve it in an incomplete and temporary way

NHS culture tend to centre on individual organisations, with payment mechanisms, accountable officer responsibilities, and performance regimes all reinforcing this. I think the emergency care crisis illustrates perfectly why we must move to a much more collaborative, system focused approach, if we are to tackle complex issues such as this one, and others such as the need to provide appropriate services for the frail elderly, or joined-up multi-agency care for those with long term conditions

Acute Trusts can improve 4hr performance by further refining their management of flow, and we must continue to do this. But it isn’t the answer even in the medium term – it is clear that radical change across the service is needed to create a sustainable urgent care system that is calmer, more controlled, and indeed safer for patients

Will the current crisis in emergency care signal a move towards ‘system’? There is a consultation out on payment systems so maybe we are approaching the moment of change? Lets see!

HSJ Roundtable

A really good discussion on ‘shifting care out of hospitals’ chaired by Andy Cowper. I must not pre-empt the published account, but heartening to see almost complete agreement on the necessary direction of travel from all parts and sectors of the service. One always picks up useful knowledge when meeting with committed and involved people, and it sounds like there is some very interesting work on integrated care happening in Southwark and Lambeth – one to follow up!

This transformation in care delivery is central to managing demand and improving care in the coming years. As with emergency care, most can see the need for a new and collaborative approach, but will the system rules, incentives and culture change to allow it to happen?  

Social Media Conference

A new experience for me, I spoke on my use of social media to a non-health conference (programme here) on the topic ‘achieving transparency through social media’. As always, preparing the talk and discussing the topic afterwards provides an opportunity to reflect. After 18 months use I think I am more transparent? Here is one slide from my talk…

What do you think? Is social media an effective tool for CEO’s, or a gimmick that wastes precious time? Let me know your thoughts!

Safeguarding children

Following on from the shocking events reported from the Oxford child exploitation trial this week, our Lead Clinician for Paediatric Emergency Medicine Dr Arne Rose has taken action to raise awareness within the Trust. It is important to highlight this, given the significant implications for healthcare providers.

Here is his email, written to staff, which was accompanied by a link to this powerful leaflet produced by Childline

Dear all,

You will have all seen, heard or read about this recent high profile case.  While such horrendous cases make the headlines, the problem is thought to be widespread.

In the article you will find a harrowing but realistic account by one of the victims and her mother.

Remember some of the markers for potential sexual exploitation are:

• Vulnerable youths being ‘befriended’ by older adult
• Child is outside their usual family home and unaccounted for long periods of the day/night
• Unexplained gifts / phone calls / texts by adults
• Sexualised behaviour
• As this case illustrates, being in a children’s home or in the care of the authority is no guarantee for protection from this crime
• Children are completely under the control of the perpetrator and may find it difficult to open up – similar to domestic violence
• Some children may present to EDs with self-harm, STIs or other symptoms (as a cry for help)

If you see a child or young person like this and you are concerned, talk to a senior clinician, discuss with a child protection expert and organise a safeguarding referral to social services.

Remember any sexual activity with a child under 13 and any sexual activity with coercion or against their will is a serious crime – involve the police after careful discussion with a senior clinician and child protection experts in the trust (available on the Safeguarding Children intranet website).

YOU MAY BE THE PERSON STANDING BETWEEN THE CHILD AND THE NEXT LEVEL OF ABUSE!

I will leave the last word to Dr Rose…

…important that it transcends specialty boundaries, eg a pharmacist might be asked to dispense an abortion regime for a young girl, a couple with a large age difference and an unhealthy relationship might present to Gynaecology, Maternity, Paediatrics, ED…

…one of the hallmarks of the Oxford case was collective paralysis by care workers, i.e. everyone suspected it was going on, but no one did anything – it’s all about empowerment and that it’s OK to discuss your concerns with the relevant people. It is going on here and sooner or later it will be on our doorstep

And finally

We co-hosted a really important conference with Dying Matters on friday, looking at compassion in care. This merits more space than I have here so I will cover it next week, when I hope some film footage will be available

A busy and varied week that started early on Monday at the London office of Monitor. Lots of calls and meetings about the Solihull Managing Director job we are advertising, but the undoubted highlight was our first leadership learning set for junior doctors!

Monitor meeting

We met with Monitor as a result of failing to meet the 4hr target for three consecutive quarters. We wouldn’t have been called if it wasn’t for narrowly missing Q2 last year – after hitting five consecutive quarters we thought it was the right time to restructure and strengthen our position but it affected our performance. And then of course, we hit a winter that has been extremely difficult across the NHS (and remains so well into Q1)

A thorough and searching examination of our team looking at our analysis of the issues, corrective actions, and associated governance, and covering both hospital and wider system factors. Now we wait for the outcome

Chief Inspector of Hospitals

Got a phone call from HSJ asking me to ‘confirm or deny’ that I had applied for the Chief Inspector of Hospitals job! Bit cheeky I thought! Not sure how I would have responded if I had applied, but I didn’t so opted to end that speculation. I love my current job and there are far too many exciting plans under way to consider leaving anytime soon

It is an important and exciting role for someone though. I expect David Behan to transform the CQC, and assessing hospital services via in-depth visits using expert teams could work very well – shades of the cancer peer review process that has been effective and is widely supported by clinicians

Candidates for our Solihull Managing Director job

Spoke to about a dozen people interested in our Solihull post. I think this is a fantastic role that is perfect for an aspiring CEO and a great opportunity to drive service integration – all the ground work has been done and all stakeholders are supportive and aligned. Closing date was Friday, and competition will be intense. By the way, all candidates names have been taken out of my diary pic above! 

I haven’t seen the final list of applicants yet, but I am confident of making a strong appointment to this really important post

Capsticks meeting on Francis implications

Spoke at this session on Wednesday evening, along with a couple of others. We had a great discussion, covering both the legal issues arising from Francis, and the practical actions we as hospitals are taking in response

I like early evening events where colleagues can debate issues of the day and share experiences. I envy those working in London where such events are more numerous!

Waverley School

Attended the school on Thursday in my capacity of Governor. This ‘outstanding’ school has just moved into a fantastic new building next door to Heartlands Hospital so we are now neighbours as well as both serving the same community

The building work clashed with some of ours and has been disruptive, but the Waverley team and the pupils richly deserve their new building and I wish them well!

Leadership session for junior doctors

Twitter followers will have seen this take shape. A shared idea with Damian Roland, an emergency paediatrician and NIHR Research Fellow in Leicester, in response to the (welcome) upsurge of interest in management and leadership among young doctors. The plan was to run an informal learning set, led jointly by an ‘older’ medical leader (me) and a youngster with an interest (Damian)! HEFT Medical Director Aresh Anwar kindly offered to run a parallel group with a second junior doc, so we could take up to 30 if needed. The Health Services Management Centre very kindly offered us accommodation

We had around 40 applicants which is brilliant, so we now have a waiting list. Our first sessions focused on ‘current NHS challenges’ and it was fascinating to explore the differing perspectives on these. The discussions were lively and friendly with great contributions from all, despite a wide range of specialties and experiences ranging from newly qualified through to those looking to consultant posts soon. The groups will choose the topics for next time – looking at the early responses a discussion with a GP commissioner is looking a popular choice!

It is energising meeting with our younger colleagues in this setting, and I left feeling we were missing a huge amount by not engaging more with this group in the course of our daily work

Emergency Care – action planning

Yes, this is still our most pressing issue. Winter pressures are now all year round it seems? We are determined to make a step change in our actions, including according greater priority to our acute ‘front door’ services. Meeting with Monitor soon – so more of this in weeks to come

Meeting with staff – Bruce

I really enjoy regular one to one meetings with staff members. I learn a lot, I receive feedback, and I understand better how the organization is feeling. I seek advice too – after all the CEO is a generalist and needs to be advised by experts. Bruce is an expert on process (Lean, value improvement, creating value) – I am looking at a 5 year plan and one of the themes must be efficiency, so this was both useful, and fascinating

One of the great joys of being a CEO is meeting our staff. This was stimulating – now, how to take it forward!

Pathology staff meeting

Was asked to give a ‘CEO perspective’ on pathology last Monday. The day I arrived our own centralisation process was in full swing, with colleagues from Good Hope Hospital moving into their new offices in Heartlands. Pathology is an interesting topic because, currently, it isn’t a ‘problem’. Our service is well run, financially stable, and devoid of quality concerns

My team is also facing up to the Midlands-wide tendering of community pathology by planning a bid, so our large service could grow still larger. I looked round our new build, which will house the latest automated track for blood testing, to be supplied by our (private sector) partner. I also had a look at the latest digital cellular pathology that we are trialling – will the next generation of histopathologists still need microscopes I wonder?

A fascinating visit – always good to re-visit ones clinical roots and great to see a forward-looking and thriving service!

Reform meeting with Andy Burnham MP

A private meeting entitled ‘Whole Person Care’ of around 20 people discussing the emerging thoughts on healthcare transformation. A fascinating debate, with a strong theme around bringing health and social care together

Given the now prolonged challenges with emergency care this was a timely conversation. Much left to do, but I left feeling energized by the discussion

Hospitals Forum / RCP Future Hospital Commission

A short HF this month, drawing up our work plan for the year and ensuring we pick up the hot topics for hospitals. Followed by a meet with the RCP Future Hospital Commission. Like us, they are looking hard at the future of hospitals and the ways in which they need to transform

We also discussed the need to present an authoritative narrative about hospitals, with the current pressures on them being a part of this. The bad press often feels disproportionate, and the notion of ‘shifting care out of hospital’ is all too frequently framed in a way that suggests hospitals are ‘the problem’. Hospitals are reeling currently, and the pressure is not self-generated. We need to understand the system contributors better, and address them, for the sake of our patients

Both the Hospitals Forum and the Future Hospital Commission believe strongly in a whole system approach to tackling our current challenges, and see a significant role for hospitals working collaboratively. It is an important message that needs communicating better

HSJ filming

Recorded a short piece to video  on Friday, for the HSJ website, along with Sharon Lamb of Capsticks. Another chance to reflect on current pressures in the NHS and think out loud about how we will move forward

Caroline Spelman MP

My last meeting of the week – Caroline is one of our local MPs and very interested in the health agenda. We ran through current pressures, and discussed our plans for developing services in Solihull. As always, she represented the public view very strongly, and we exchanged thoughts on what we are both hearing from people in the Borough

Regular dialogue with MP colleagues is very important. As I have written many times, our challenges are complex and a common understanding makes for clearer communications from us both

Well it is April 1st and the start of a new era for the NHS. Over the weekend I have been alternately reflecting on the year to come, and fretting over my hospitals urgent care position (4 day breaks are difficult). Here are my views about the challenges for 2013/14…

Most pressing is the pressure on hospitals. I have referred elsewhere to our recent risk summit, prompted by our poor 4hr target performance. My responsibility is clear enough, but I keep coming back to the fact that the whole system has struggled this winter. Urgent care outside of hospitals is in disarray, and things are just as difficult in integrated Wales, which is depressing as I was hoping integration was part of our solution! 

A positive is GP leadership of commissioning. I am not convinced of the need for commissioning at all, but I am truly heartened by the relationship we are developing with our CCG colleagues. Patient focused, clinically appropriate, collaborative and practical. I worry though, about the scale of challenge they face, and their ability to differentiate themselves from the previous system and bring about the much needed change of emphasis

Reconfiguration is necessary but doesn’t seem to be getting any easier. Ruth Carnall advises courage is necessary, but will we see it? I still believe the measurement and publication of outcome data will help this debate onto a rational footing, but the present issue in Leeds suggests this won’t happen quickly or easily. I suspect we will see a number of ‘politics v data’ debates this year, and interesting to see that MPs are now adopting the time-honoured tactic of questioning the data, like hospitals and medics before them 

Some of us have been advocating more openness for a while, but it is now a headline topic. The duty of candour and re-statement of the rules on gagging clauses will not change my practice, though it is embarrassing that they are needed. The new GMC Duties of a Doctor are interesting in this respect, and the social media stipulations in particular are stimulating lively debate

Money will become a bigger issue this year. The discussion is moving from local cost improvements to the viability of organisations, with many unlikely to be sustainable in their present form. Back to reconfiguration again – a massive leadership challenge for NHS leaders and politicians alike

Talking about leaders, a key role for them is to look beyond the present, to see the bigger picture and to set longer term goals. How about ‘integration’ and ‘shifting care into the community’? Conference perennials but will we see movement on these this year? Maybe the Norman Lamb pioneers will show the way? 

Transformation is crucial, but what impact will tendering have? I am going to be honest and say I don’t know. The ‘idiots’ guide’ in the HSJ was useful, but I suspect that none of us will know unless and until the new rules are tested in law. Unless we are saved by a prayer

Most important of all, of course, is the need to shift the emphasis and culture of the NHS to create a genuine focus on caring, compassion, listening and openness. This is the real prize – everything else is a distraction. To do this will require big changes, a critical one being a step improvement in staff engagement and morale. NHS workers are great people, but we have lost them

This is my number one objective for the coming year because, for hospital Trusts, success will no longer be based on ‘inputs’ such as the range of tertiary services, number of academic appointments, size of buildings or turnover, or even heritage. In the ‘new era’ it will be on the ‘outputs’ produced – good clinical outcomes, excellent safety records, and positive patient feedback will matter most, and only valued and supported staff will deliver these

Our NHS feels very unsettled today, with an uncertain year ahead. There are significant challenges, but there are opportunities too. Capitalising on the latter, and staying focused on what is really important, is the leadership task for 2013/14

 

 

Hoping to take a few days off next week, so the next diary will be after Easter. This week was a difficult one

Urgent care pressures

These continue to be severe across the Birmingham conurbation, with all hospitals reaching high levels of escalation at times. The coldest March in 50 years is adding to the pressure. An email chain circulating between ED doctors shows there is a similar situation everywhere, with a view that insufficient capacity in the system as a whole is leading to queues and overload in Emergency Departments. This is concerning to everyone, as the safety of our patients is paramount. There is worry too about the launch of 111 and the impact this may have, and a broad consensus that slowing discharge processes are at the root of the capacity constraints. Many feel that community health and social care services are unable to escalate at the scale and pace needed during high demand periods, creating significant additional pressure on hospitals

Of course, for acute Trusts this is also an important performance issue. In my position I have to get the balance right between managing performance, ensuring patient safety, and acknowledging the human factors which are significant in a workforce that has been working in near crisis conditions for many weeks now

I have called our staff together next week to talk this through, to recognise their continued commitment and to share with them our plans to invest significantly in our acute and ‘front door’ services

NHS Midlands & East Clinical Summit

Attended this big event on Monday. A little early for the DoH response but very helpful to hear Robert Francis give a very powerful personal summary of his report, and Jeremy Taylor of National Voices present the patient perspective. Coffee time discussions with colleagues from across the region were illuminating as always. Interesting to hear experiences of more ‘risk averse’ decision-making by clinical professionals since the publication of the Francis report, resulting in longer hospital stays and consequent impact on Emergency Departments

Was sorry not to hear David Behan and Jane Cummings speak in the afternoon, but had to leave at lunchtime (those urgent pressures again)

Breakfast event at Kings Fund

Took part in a breakfast time debate entitled ‘Shifting care closer to home: slogan or solution’ on Tuesday. Together with James Reilly and Nigel Edwards we debated the issues covered in this blog. Much of my piece discussed the future role of specialist physicians in providing ‘non-acute, health maintaining’ care – it seems to me that they and their teams have a critical role to play in ensuring specialist knowledge and expertise is available to patients without having to access the acute hospital in the traditional way.

This is one of the major transformation challenges, and an important part of the future role of acute hospitals

Risk Summit

A difficult meeting, convened because of our poor recent performance against the 4hr target. I have spent countless hours analysing this, trying to understand the causes and put in place the correct actions and processes. My team are the same and I am aware most of us wake at night thinking about it. Our new GP commissioner colleagues are similarly embroiled, and were brilliantly supportive. This was about us, not the wider system, but it did feel unsatisfactory that the critical wider context I have described above, and that many around the table acknowledge privately, was not discussed

We took stock afterwards, and reflected long and hard. This will be a turning point for us, we will not be in this situation again. It will require significant internal realignment around our ‘front door’ services, and involvement in pre-admission and post-discharge care too.  I will share these plans over the coming weeks, starting with the staff meeting next week.

Webex on Social Era

After the Risk Summit my week wasn’t quite over. Once I managed to log in, I joined and co-hosted a webinar with Helen Bevan and Mike Baldwin. The topic was ‘ How ideas about the Social Era could transform healthcare thinking’. It was a fascinating discussion and one worthy of repeating to a larger audience I’m sure.

An uplifting end to a difficult week!

I didn’t have time to write last week so this entry combines the last two weeks

HSJ roundtable on whistleblowing

Nipped down to London for this discussion, a timely one in view of the considerable interest in the topic at present. I’ve discussed this elsewhere, but it set me thinking that the major issue in the NHS currently is staff morale and engagement. And despite all the discussion at conferences and local level, we know the answer. Ask the staff and the answer has always been the same – ‘low staffing levels and a feeling of not being valued’. Maybe we need to address these, rather than keep asking in the hope the answer will change to something that’s easier to fix?

The roundtable discussion is now published here

Joint Overview and Scrutiny Ctee

Attended the joint Birmingham and Solihull OSC to talk about the impact on hospitals of the Francis report. An interesting session with a well informed and realistic committee. I talked about the need to give greater priority (and investment) to acute general services, and flagged up that this would require difficult decisions about service change as a consequence

I’m wondering whether the DoH recommendations emanating from Francis will be peripheral compared to the huge central themes about a safer, more caring and more transparent NHS. They feel like the real challenges for us? 

Members meeting at Solihull

A great attendance at this open meeting for our members and local public. In two hours of lively discussion we ranged from national issues (finance, Francis, government pressures) to local ones (emergency services, future of Solihull Hospital, integration with community services) through to individual experiences of our services, both good and poor

I’m hearing a real desire for more local determination of service priorities. The strong central drive around targets and other imperatives, and the political concerns about ‘post code variation’ have stifled this – time to let go a little?

National Medical Director’s Clinical Fellow scheme

I had a really great discussion with one of our recently qualified doctors who is thinking of applying for one of these posts. I’m seeing a developing interest in leadership and management amongst our young doctors, and colleagues are picking it up too – I felt more optimistic about the future after this conversation

Radio WM appearance

Quick appearance on the Adrian Goldberg show on Tuesday morning. Talked about care of the elderly, which gave me a chance to mention that we have a BBC television crew in our hospital preparing a documentary on our elderly care services. After that callers phoned in with both good and bad experiences of our hospitals.

Two callers said we don’t provide pillows on our A&E trolleys – I thought we did but clearly something I need to check on!

Change Day Twitter chat

With Johnny Marshall and Fiona Rodden of Linking Leaders I led a twitter chat on leadership to mark NHS Change Day. Using the hashtag #NHSchange we had a very lively debate, covering many aspects of ‘new’ leadership and how leaders need to act in the future NHS. Values, staff engagement, and collaborative behaviours were mentioned a lot, and rightly so.

The hour went by in a flash and there have since been many calls to repeat the discussion. Twitter makes these very easy to arrange and publicise, and all at no cost

Governors away day

Despite the need for some of us to return hurriedly to our still highly pressured hospitals, we had a good day with our Governing body on friday. We talked about emergency pressures, the need to develop a 5 year plan based on achieving top decile outcomes, the Francis report, and the new governance framework. We finished with an excellent talk from Professor Calum Paton of Keele University on ‘The Re-Re-Re-Reform of the NHS’! Structure, politics, culture, markets, Francis and more, followed by a diverse discussion on the role of academia as critic, purchasing versus commissioning, the sparsity of evidence-based policy, and the feasibility of a ‘targets without terror’ regime

Entertaining and thought-provoking stuff and great to have this level of discussion with our Governor colleagues

Kings Fund blog

This is published here now. I made some suggestions about how we might bring about the much needed culture change within the NHS. Please do comment if you have a moment! 

In next weeks diary …

The Midlands and East SHA are hosting a clinical summit on the implications of the Francis Report, with Robert Francis himself attending. As we approach Easter our emergency pressures show no sign of abating, and at the end of the week a risk summit is being convened as a result of the difficult winter and the impact on our Trusts performance

Main theme of the week continues to be our urgent care pressures – it is still proving very difficult to break the cycle

Emergency pressures

The urgent pressures in our hospitals continue to dominate, the key being our inability to create sufficient discharges to free up the system and allow processes to operate smoothly. I am on call for the conurbation this week so have joined conference calls and it is clear the pressures are widespread. The entire system has been running at capacity for several months now, so small activity spikes quickly precipitate a crisis

It is impossible to be part of this and not form the view that we have to organise things differently. Too many years focusing on performance managing acute hospitals (because of targets) mean that other parts of the system now look unfit for purpose. Our new commissioning colleagues must look at how primary, community and social care operate in respect of urgent care – otherwise our ‘always open even when full’ hospitals will continue to struggle

Everyone now talks of the need for culture change in the NHS. One aspect of current culture is the ‘acutes are the problem’ mindset. The view that acute hospitals ‘drive demand’ by keeping capacity open, and swallow up disproportionate resource in the process, has led to too little attention on other factors that impact on activity and demand. The bizarre decision to reduce the acute tariff by 70% is indicative of this malign view of our hospitals, as are the swinging financial penalties for performance issues that are not completely within our control

The Transforming Community Services process was affected by this aspect of NHS culture too, resulting all too frequently in community services being placed ‘anywhere but the acutes’. Sometimes this may have been appropriate but, as a consequence, the creation of integrated services is now more problematic

Returning to the here and now (!) here are three practical steps discussed this week:

1. On Monday (tomorrow) our new acute medical clinics open, at scale, to create and develop an increasingly ambulatory approach to our acute medical services. This is an exciting development that we have created jointly with our GP commissioner colleagues. Watch this space!
2. We agreed a much streamlined process of recruiting to vacant clinical posts. Despite our best efforts, it remains slow to replace staff who leave. From now, the recruitment of most ward staff will start immediately the Ward Sister gives the go ahead.
3. We have agreed to implement ‘supervisory’ Ward Sisters across the Trust. This takes these crucial people out of the ‘numbers’ and allows them to effectively manage the ward and their staff. Presently, with the best will in the world, they are simply too busy to focus on early in the day discharges, or spend more time explaining things to patients, or encouraging and supporting the development of younger colleagues. 

These are significant developments, but I will continue to press for whole system change. It is increasingly apparent that acute Trusts will need to drive some of this too, by expanding their services into areas traditionally provided by others such as whole of year care and post-discharge re-ablement

Breast Friends meeting

Met with this group to update them on progress with this very difficult issue, and to discuss the thinking behind asking Sir Ian Kennedy to conduct a review for us on ‘raising concerns’.

We had a good discussion – the whole area of ‘whistle blowing’ is topical right now and I am hopeful that this review will result in some constructive and practical proposals for change

80 years of Birmingham Chest Clinic

Our city centre Chest Clinic celebrated 80 years this week. The teams provide a range of chest medicine and sexual health services from this old and characterful building. I saw fascinating demonstrations of the work carried out on tuberculosis, occupation lung disease and lung fibrosis, and our Chairman made a presentation to a member of staff who has worked there for 50 years!

I also bumped into a recently retired consultant who taught me as an apprehensive junior medical student. It wasn’t quite 50 years ago but suffice to say that I recall watching the Falklands Task Force sail on TV in the students common room, and our ward was in the ‘new block’ that is now the oldest building on our site!

Lots going on, as ever, during this half term week. Our hospitals remain under significant emergency pressure as what has been a difficult winter shows no sign of abating

Executive Management Board

Our monthly meeting of Exec Directors and senior clinicians. Two dominating but contrasting themes, starting with a discussion about our current performance. Our hospitals have been under severe urgent care pressure for several months now, and staff are tired and stressed. Discharging patients is difficult and laborious, and the proportion who are ‘clinically stable’ has risen to around 60%. On Monday, in one hospital, we admitted 109 people with acute illness, 29 more than the usual number. That is sufficient to fill a whole extra ward (that we did not have available) and will have an impact that takes the best part of a week to manage.

The eternal dilemma for us as the management team is…how much is this caused by demands on the hospitals we cannot control, and how much is caused by our own operational deficiencies? And, are the two linked by the inevitability that our own processes will slip after months of unrelenting pressure?

“According to the 4hr target we are ‘failing’. But I defy anyone to visit our acute areas, and see the huge effort and commitment and effectiveness of our staff, and still feel either that we are failing, or indeed that the target gives a true reflection of what is a very complex situation?”

The second theme was our longer term strategy. We agreed to put the Trust on a 5-10 year plan to really drive our priority of ‘safe and caring’. What do we need to do differently over this period to achieve top decile levels of safety and patient satisfaction? How will our decision-making need to change, and do we need to re-prioritise our resource allocation?

“Exciting stuff, but essential – concentrating solely on the ‘here and now’ will mean we remain in the middle-ground of performers when we could achieve so much more in the areas that are important to our staff and patients”

NHS Change Day

Quick planning meeting for this very worthwhile initiative that we are keen to support. As a Trust we will make some pledges around safety, workforce, and patient experience that will link to our plans described above. For me, I will be making a joint pledge with Dr Johnny Marshall and Fiona Rodden of Linking Leaders to conduct a Twitter discussion on ‘leading differently’ across the NHS

“Details including hashtag and times to follow soon!”

Planning for CLAHRC 2

The bids for the second phase of the NIHR Collaborations for Leadership in Applied Health Research are being prepared. The CLAHRC links the NHS with high quality research, and is aimed at putting research into practice for patient benefit. We are looking at some projects around population health, ambulatory acute medicine and chronic disease management, and children’s services – all really important areas

Hospitals Forum

Held the third meeting of the NHS Confederation Hospitals Forum this week. It is important to ensure there is a strong voice for hospitals within the NHS Confederation, given that well over 90% are members. It is also crucial to use the linkages with commissioning and other parts of the NHS that sit within the Confed, because I have no doubt at all that hospitals can and must play a wider role in health provision in the future. We discussed Francis and related issues, and also the proposed (and welcome) changes to the national contracts for NHS staff

“We unanimously endorsed the changes to Agenda for Change and very much hoped that these are agreed at the NHS Staff Council when it meets next week”

LETB authorisation

On Friday we had the authorisation meeting with Higher Education England for the West Midlands Local Education and Training Board (I sit on the LETB as Chair of the Birmingham and Solihull LET Council). These reforms to training and education have been less discussed than other elements of the recent Health and Social Care Act, perhaps because they are quite technical? They are important though because they give providers (employers) a much greater role in the planning and management of training and education

“Given the need for service transformation, it has never been more important to get workforce planning right. I have high hopes for the West Midlands LETB – it has started well and has enthusiastic support and buy-in across the patch”

Kings Fund blog

Regular readers will know that I promised a follow up blog with some suggestions for changes we could make as a response to Francis and the need to change culture. However this week I have written a blog on this topic for the Kings Fund ‘Time to Think Differently’ programme so I won’t pre-empt this by blogging here.

“Here is a link to the article”

Unsurprisingly, the publication of the Francis report has led to much reflection among managers, clinical leaders, and health commentators. My (pre-publication) concerns are here, but we won’t get answers for a while, until the government has taken a view on the 290 recommendations contained within the report.

But what about doctors? What are some of the implications for the profession?

Doctors do not emerge from Francis unscathed. Whilst the main deficiencies were in ward-based nursing care, mortality rates were persistently high and doctors failed to raise concerns effectively. Much has been made of the ‘climate of fear’, but I struggle to believe this alone explains why concerns were not raised early, loudly and persistently. After all, there is safety in numbers and many hospital chief executives have lost their jobs over the years as a result of a Consultant Staff Committee vote of ‘no confidence’ – why not at Mid Staffs?

I have argued for a re-wording of the GMC’s Duties of a Doctor to make much more explicit the duty to raise concerns about wider care issues involving patients other than their own, for instance elsewhere on a ward or in a hospital. The second duty ‘Protect and promote the health of patients and the public’ is perhaps too general in this respect?

There are implications for services too, that I have alluded to in my Weekly Diary and which need considering in detail. Essentially, the quality and safety concerns relate to our acute general services, and predominantly medicine. And if we are honest, these have been less glamorous areas of practice, and less invested in, than many of our specialties. Specialists have progressively pulled out of the general on-call rota, knowing that the way to build a career and a reputation is to focus on their work as an ‘-ologist’.

But most of the work of an acute hospital is in ED, acute and ‘general’ medicine, and care of the elderly. If we are to make a step improvement in quality standards, we need to invest a greater proportion of our resource in these areas. More doctors, and maybe more nurses on wards with high acuity?

Such a move will have knock-on effects. I cannot see how to increase resource here without decreasing investment elsewhere. Add in the move to 24/7 acute services, and we have a huge need for new investment. That can only mean spreading the available resource less thinly and reducing the range of services on a particular hospital site?

It can be argued that, anyway, concentrating specialist services on fewer sites leads to better outcomes, with acute stroke or PPCI or cancer services often quoted as examples. But perhaps it needs to go further, with improvement of acute general services as the main driver?

As I see it, I will have to orientate my hospitals more strongly around acute services if I am to rise to the Francis challenge and really improve care quality standards with more staff, more capacity, and more time to care. If this leads to relinquishing some ‘high end’ services then many doctors will be concerned, because building a specialist service portfolio is deeply ingrained in medical culture. It is how progress is judged, and it is often the way by which hospitals are judged when selecting jobs.

If Francis provokes the development of a new world, maybe it will be a world where ED, acute  and general medicine, and elderly care medicine, are higher up the unofficial hierarchy – at the top even? Any thoughts?

This blog was written for Hospital Dr and originally posted here on 18 February 2013

This was a week of thinking and talking, mainly about the implications of the Francis Report. I’d originally booked the week as holiday, but several events later it was down to just two days off! I did manage to publish a guest blog on our brilliant VITAL products – have a look here if you are interested in staff training and development

2048 Group

I was asked to speak on ‘Challenges faced by a hospital CEO’ to this varied group of informed and interested individuals. No doubt about my major challenge – how to transform hospital care so that we prioritise, and continually improve outcomes, safety, and patient experience. The more I think about it, the more radical the effect of doing this will be, because more investment in ‘front line’ areas must inevitably mean less somewhere else. Where will this be and how will we manage the impact it will have?

If we implement the ethos of the Francis Report, and genuinely make quality the organising principle of healthcare delivery, and we should, then I think it will prove more transformational than even the recent Health and Social Care Act. A topic to expand on in my next blog!

Reform Conference

Attended ‘The New NHS’ conference on Tuesday and heard from both Jeremy Hunt and Liz Kendall. The speech by Jeremy Hunt was firmly based on care standards and the patient and the importance of ‘what cannot be measured’. I got the chance to ask him about local versus national priority setting, because it seems to me that greater public involvement (a good thing) will inevitably place managers in a conflicted position – wanting to take forward locally-determined priorities whilst still remaining under strong central direction. He seemed to acknowledge this, though he did say in answer to a following question that ‘there should only be one measure of success across the NHS’!

Liz Kendall gave a passionate speech, and talked well about the need to create alternative models of care for people with long term conditions, quoting a gentleman she had met who kept himself in good health using telemedicine and home technology support.

It feels like change is coming. Is the age of ‘top down, target-driven’ about to give way to a period where success is defined more broadly, and by what the patient says rather than by numbers the NHS generates?

Health and Social Care Reform, University of Birmingham

This was a working dinner bringing together experienced individuals from the worlds of public health, social care and local government, academia, and the NHS. We looked back at what had worked well in the past, and what had been less effective. What lessons could we learn and use in our forward planning? On our table we debated the impact of continual structural change – I learned that there was a spike in the incidence of childhood tuberculosis in the city every time a reorganisation occurred. Fascinating stuff.

My resolution from the evening was to do something innovative around joining forces with social care in the city. The constant operational pressure across the conurbation is bad for patients and staff – we have to do something differently, and soon

HSJ Round Table

Was privileged to take part in this structured debate about Francis, and the practical implications of the many recommendations contained within the report. I hope we use it as a catalyst for the seismic change in approach that is now becoming long overdue.

No spoilers – it will be published very soon I’m sure!

Back at the office…

Returning from London on friday I spent the afternoon at Heartlands Hospital. My letter to all staff about Francis has gone out, but I wonder if most staff will read it. It has been another difficult week in all of our hospitals – the operational pressures are unrelenting and everyone is tired. Trying to incrementally improve operational efficiency in hospitals when the whole system needs transforming feels more and more like the wrong approach. Blaming acute hospitals for ‘poor’ 4hr target performance has become a displacement activity – CCG’s must avoid falling into the same pattern of behaviours as their predecessors and take a close look at primary care access, or community service design, access and efficiency

We (I) have to put some of the thinking from this week into practice. It isn’t just my organisation, as this article highlights. Our hospitals are continually struggling under the weight of a whole system that is increasingly unfit for purpose. Our new system leaders must understand this, and resist the pressure they are coming under to focus narrowly on the 4hr target and simply push hospitals harder. We cannot continue as we are, for the sake of both our staff and our patients