Chief Executives Blog – September 2014

Quite often I find myself talking about what we do at the Trust and illustrating my stories with a picture of someone juggling.  Whether someone is working clinically or in a leadership role, trying to do several things at the same time can be both occasionally difficult and slightly exhausting.  The dropped ball is often more visible than the many kept successfully in the air.  Over the next few days I am preparing, with Board colleagues, for our upcoming Annual General Meeting (September 25th 18.30 in the Postgraduate Centre at City Hospital).  And considering which issues of excellence and of concern to focus on when we see the Care Quality Commission (CQC) team in October for their inspection visit.  That preparation has me thinking even more than is usual about what we do best and where we have to improve.  The two things, excellence and error, do not “trade off”.  Both are equally important to driving up standards of care and quality.

Two recent stories in the local news media of course do illustrate some of the challenges of improving care.  We have admitted liability for errors in 2011 in the care of a young local resident.  Our surgical practice has changed, but we should not have needed to make a mistake to have that happen.  I apologised earlier this year, in addition to the apology given at the time.  What does not come across clearly in a story of NHS error, and a terrible mistake, is what has been learnt and done to stop that happening again.  Three years on, we are a safer place.

Meanwhile, we have set out to change our day to day practice around consent.  The Trust Board as a whole wants to see improvement.  That determination was illustrated with phrases about scandals and blunders in our local press earlier this month.  Our openness about what we need to improve can always give rise to that kind of misunderstanding.  We want to undertake consent in the very best way, driving for standards not always seen in the NHS.  Whenever it is possible to do so safely, we need to give our patients all the time that they need to consider the treatment options they have and the risks they pose.  For planned care that means having an initial discussion about outcome before the day of the procedure.  We know that typically most teams do the right thing, most of time, and pressure of time is typically the issue when we go too fast.  Our consent changes are designed to make it easier to get this right, but also to be very explicit about consequences where an individual is consistently unable to meet our core standards.  We want the people we serve in our local community to have confidence and trust in us: Trust that we will be open; confidence that we will strive to improve good parts of our service to make them even better.  A part of that trust is knowing that our leadership team will face individual issues of non-compliance, as well as developing plans for system improvement.

Having a candid conversation about safety is fundamental in our organisation.  Over many years we have been explicit about the long term future of care here: Right Care, Right Here.  A bright future but one that has to be financially sustainable.  We intend to invest in our workforce, our technology and our estate.  We intend to provide better integrated care.  But we will be doing that with a smaller workforce, because we need to operate with a lower paybill, as the NHS looks to treat many more patients with the same amount of money.  Of course, doing that is very difficult.  Changes routinely alter how we work, adapt longstanding practices, and disrupt in positive, but also in very negative ways, team practices.  Both out of concern and resistance, arguments against change are framed around the quality and safety impact of individual changes.  In our Trust we assess each scheme for workforce change through our medical and nursing director.  But we also track impacts after implementation, not just risk assess things beforehand.  That tracking will be increasingly small scale, as the effects of even very big changes are felt very locally.  A change might work well in one team, but the same change may be problematic in another team.  We need to intervene to sort out implementation, we cannot react by never trying to change.

One of the challenges for juggling leaders is to assess the difference between a concern expressed with evidence and a concern expressed by instinct.  That challenge is not simply an evaluative judgement, but also about keeping an open mind to who is raising a concern.  We are committed to our whistle-blowing model (See poster here) launched earlier this year.  We make no assumptions about someone raising concerns based on their prior history of raising concerns.  We want everyone to speak up, even if they simply think we might have a problem.  That openness inside our Trust is something to which I am deeply committed, as is our Chairman Richard Samuda.  That that conversation sometimes gets reflected in the press, or slightly distorted in the retelling, must not, and will not, inhibit us from trying to create an organisation, a Trust, in which everyone matters.

Our CQC inspectors are about to confirm the venues and timings for their public meetings.  One we know will be a drop-in session on Thursday September 25th from 14.30 at City Hospital (See information here).  Another will be in early October at West Bromwich Town Hall.  Likewise, our staff will be able to meet in open forums with inspectors, or raise issues, strengths and concerns directly with inspectors.  Consistent with my view about the media and about our safety culture, we will be actively encouraging everyone to meet the inspection team.  There is a huge amount of brilliant care and dedication in our teams.  There are also frustrations that employees have about the organisation, and the leadership, as well areas of care where we are determined to get better.  I really hope that the inspection process and the outcome, which we will know probably in December, reflect accurately and fairly on all of those issues.  I am also delighted that our Inspection Chair is a nurse and midwife from an NHS community trust – as we work to become an integrated care organisation this inspection will be an important marker of what has been achieved and what is left to do as we work towards our 2020 vision.

Last week we had our 2014 Beacon Services final judgement panel.  In 2013 we awarded beacon status (our brightest, best, most innovative) to our gastroenterology, breast, and gynaecological cancer teams.  Our four finalists for two awards this year were of a fantastic standard – our stroke team who have transformed outcomes in the last eighteen months and are now rated among the top 16% of units in the country; our heart failure service which bridges hospital and community care and which, over more than decade, has sustained great standards of practice and research; the Trust’s Wellbeing team who are doing so much to promote our Public Health agenda and to ensure that mental health in our staff and managers is high on our agenda; and the Sandwell Childrens’ Therapies team working in schools and homes to deliver advanced clinical practice and to train parents and teachers to look after young people.  All could feature in the strengths presentation our Board will make to the CQC.  All have something to teach me and other leaders about how to make change happen in our system.  All offer a chance to publish data on outcomes and improve care across the wider NHS.  I am both humbled and proud of what these colleagues are achieving.  Juggling successfully is a habit which can be learnt with practice.

Toby Lewis

Chief Executive

Follow me on twitter at @Toby_LewisSWBH