High mortality rates sparked an investigation by NHS England medical director Sir Bruce Keogh (left) that resulted in 11 trusts being placed in ‘special measures’. The impact on the trusts’ nurses has been surprisingly positive, however. Alison Moore reports
Review rouses staff to strive for better care No one enjoys being the subject of an investigation, but for the 11 trusts at the heart of the review led by NHS England medical director Sir Bruce Keogh, there has been no escaping some unpleasant conclusions – or the media spotlight. Only three of the 14 trusts examined in the Keogh review avoided being put into special measures, which carries the threat of board changes if they do not
improve. But, perhaps surprisingly, senior nurses at the 11 trusts say the process has had a positive effect, galvanising staff to strive for better care. This is partly because the review process, which was intended to be supportive, talked about the elements of care that really matter to staff – one nursing director describes it as ‘the stuff that gets me up in the morning’. Concerns about nursing staff numbers featured
The Keogh review of hospitals with high mortality rates Following the publication of the Francis report into care failings at Stafford Hospital, NHS England medical director Sir Bruce Keogh was appointed by the government to conduct a review of the quality of care and treatment provided by NHS trusts with high death rates. A total of 14 hospital trusts were investigated as part of the review. The review process involved examining data, sending a rapid responsive review team into each trust and holding risk summits. In some cases, the team asked for issues to be addressed immediately, such as staff being expected to work 12 days in a row. When the review reports were published in July, all but three of the trusts – Colchester, Dudley and Blackpool – were placed in special measures. They will face monitoring against action plans and a further review within the year. Ultimately, their boards could be
NURSING STANDARD
dismissed or they could be placed in special administration and broken up. Last month, health secretary Jeremy Hunt announced that each of the 11 trusts under special measures will also be required to enter into a partnership with a high-performing trust. Leaders from the high-performing hospitals will work with the 11 trusts to help them improve and escape special measures. Meanwhile, the foundation trusts among the 11 will have their freedom to operate as an autonomous organisation suspended. The capability of leaders at all 11 trusts is under review and managers will be removed if they are seen to be holding back progress. Each of the 11 trusts will also have an improvement director, who will monitor improvement. Mr Hunt said he was confident that support from ‘inspiring NHS leaders’ would ‘get these hospitals out of special measures and on the road to recovery’.
in several reports, along with the ability to deliver quality care. And, although the trust reviews found many problem areas, they were often issues that nurses were already aware of and that directors of nursing had been trying to address. Brendan Brown, director of nursing at Burton Hospitals NHS Foundation Trust, says the review highlighted that the work they had been planning was on the right track. ‘My staff did me proud,’ he adds. ‘It has given us an impetus to get on.’ Karen Dunderdale, director of nursing at Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, says: ‘It was incredibly reassuring. It gave us confi dence that the improvements we were seeing in nursing were going in the right direction.’ The reviews increased the pace of change at many organisations. Plans for improvements are being completed in a matter of weeks, rather than months. Inevitably, however, this has put pressure on the small number of senior staff who can lead such initiatives. Boards and commissioners have been persuaded of the need for investment, especially in nursing staff. ‘We have to be realistic about the fi nancial situation, but it is about doing the things that are must-dos,’ says Dilly Wilkinson, deputy director of nursing at the George Eliot Hospital NHS Trust in Nuneaton,
october 23 :: vol 28 no 8 :: 2013 23
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 24, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
which is recruiting more nurses. ‘Some things have to be done.’ Many trusts’ responses to the review have included a decision to increase nursing numbers. Although some trusts did not report low staffing numbers initially, as the review process dug deeper it became clear that the figures reported at board level did not always tally with the experience on wards. At Sherwood Forest Hospitals NHS Foundation Trust, executive director of nursing and quality Susan Bowler has been carrying out a nursing review that will be presented to the trust’s board. She believes it will lead to a substantial increase in spending on nurses – the Keogh review identified nurse staffing at night as a particular issue. At United Lincolnshire Hospitals NHS Trust, interim director of nursing Eiri Jones says she felt there was a shortfall in nursing numbers when she was appointed a year ago. Additional investment of £7 million over two years has now been agreed. ‘Keogh said that we needed to increase nursing numbers faster. Together with our clinical commissioning group, we are doing this,’ she says. The trust now aims to have a ratio of one nurse to six or seven patients during the day, and one to nine or ten at night. The extra funding will pay for about 100 extra nurses. The trust has recruited 165 nurses
Recruitment
Basildon and Thurrock University Hospitals NHS Foundation Trust has already filled most of the additional 200 nursing posts it concluded it needed. It has also created a clinical sister post to focus on consistent and standardised practice on wards. Many of the trusts recognise that working with universities and encouraging nurses to return to practice will need to be part of a sustainable solution to recruitment. United Lincolnshire is working with the University of Lincoln, which has recently launched an adult nursing course. At George Eliot, changes to the recruitment process seem to be bearing fruit – applicants are invited into the hospital for a day and values are emphasised. Trusts are examining skill mix and the way staff numbers are linked to demand during the course of a day and week.
24 october 23 :: vol 28 no 8 :: 2013
NATHAN CLARKE
Basildon and Thurrock University Hospitals Buckinghamshire Healthcare Burton Hospitals East Lancashire Hospitals George Eliot Hospital Medway North Cumbria University Hospitals Northern Lincolnshire and Goole Hospitals Sherwood Forest Hospitals Tameside Hospital United Lincolnshire Hospitals
since April, but many of these are replacements for retiring staff. The challenge is finding new staff. Historically, some of the trusts involved in the Keogh review have had difficulties recruiting – geographical and professional isolation is a theme in the Keogh report. A number of trusts are looking to recruit workers from Spain and Portugal. There is an existing Portuguese population in Boston, where United Lincolnshire runs the Pilgrim Hospital. Ms Jones hopes this will be a draw as it recruits in Portugal. Medway NHS Foundation Trust, which was not criticised for its staffing levels, is spending an extra £1.6 million on nurses and £700,000 on midwives to improve ratios. It, too, is looking to recruit abroad.
SUMMARY
The 11 NHS trusts on ‘special measures’
Chief nurse at Medway NHS Foundation Trust Steve Hams: ‘We welcomed the Keogh review.’ He is pictured with head of nursing Jayne Gray (centre) and deputy chief nurse Ursula Clarke
A review of NHS trusts with high mortality rates resulted in 11 trusts being placed in special measures. This means they must improve or face being broken up or having their boards dismissed. Despite this, and the pressure of being under the media spotlight, many nurses in the 11 trusts have found the process energising. Author Alison Moore is a freelance journalist
United Lincolnshire has an assurance process in place, which ensures each ward has the right number of staff for its beds – and, if necessary, the number of beds will be reduced. The trust is also planning annual reviews of its nursing needs to inform workforce and financial planning. Maintaining staff morale is vital. Ms Jones from United Lincolnshire identifies fast results and good communication as important. ‘We are used to being under the spotlight, but there is the potential for it to be demoralising for staff. We do our best to ensure staff know that there are good things too.’ At Sherwood Forest Hospitals NHS Foundation Trust, staff coped well with the Keogh review team – but then they had a Care Quality Commission inspection
NURSING STANDARD
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 24, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
‘We found the revieW process motivating’
immediately afterwards, which affected morale. Many of the trusts are now talking about transparency, openness, listening and raising concerns – however, not all of the 11 trusts approached were willing to be interviewed for this article.
Staff feedback
East Lancashire Hospitals NHS Trust says that two days of ‘listening events’ provided it with feedback from staff that will inform its nursing and midwifery strategy. At Sherwood Forest, quality is now predominant on the board agenda. Northern Lincolnshire and Goole has looked at care of the deteriorating patient and improving the use of early warning scores, as well as preventing falls.
NURSING STANDARD
A number of the trusts have seen changes in nursing leadership in the past 12 months, and the Keogh review has emphasised the importance of clinical leaders. At East Lancashire Hospitals NHS Trust, the acting director of nursing is planning ‘back to the floor Fridays’ for herself and her deputies, so they can experience clinical practice on the front line. At Medway, chief nurse Steve Hams sees ‘authentic leaders’ as key to improving the engagement of the workforce. Part of his role, he says, is building confidence in the trust’s nurses, so they can aspire to great care. He also points out that small lapses in standards can spread rapidly. ‘If I see a piece of litter on the floor and ignore it, then I will have a dirty hospital,’ he says. ‘So, I pick it up’ NS
It would be natural to assume that the Keogh review process would be universally painful for trusts. But Steve Hams, the new chief nurse at Medway NHS Foundation Trust, insists it has ‘energised’ his staff and been far from negative. ‘We welcomed the Keogh review team with open arms and found the process motivating,’ he says. Part of the reason may be because the Keogh teams have looked at issues that matter to nurses, including staffing numbers and various aspects of care. ‘It probably reinforced what staff had been feeling. It validated their concerns and has created a great deal of energy in the organisation to get it right and get us off the naughty step,’ adds Mr Hams. Since the Keogh report was published, the trust has launched a ‘reboot’ initiative that encourages staff to raise and address problems, without having to seek permission. By the end of the first week of the initiative, all patients were being nursed in their specialty area, which was a major achievement. The trust was also more successful in discharging patients who are clinically able to leave, but are prevented by non-clinical reasons. But it is as much about raising confidence among staff as solving specific problems. Some staff were used as ‘JDIs’ – ‘just do its’, a cadre of enthusiastic go-getters who were prepared to cut through bureaucracy to get things done and improve care. ‘Back-office’ staff, who would not normally have contact with patients, spent time on the front line to see the difference that good care makes. The enthusiasm was palpable, but Mr Hams wants to see it sustained. Realistically, the exercise might need to be repeated every quarter, he suggests. october 23 :: vol 28 no 8 :: 2013 25
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 24, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Review rouses staff to strive for better care No one enjoys being the subject of an investigation, but for the 11 trusts at the heart of the review led by NHS England medical director Sir Bruce Keogh, there has been no escaping some unpleasant conclusions – or the media spotlight. Only three of the 14 trusts examined in the Keogh review avoided being put into special measures, which carries the threat of board changes if they do not
improve. But, perhaps surprisingly, senior nurses at the 11 trusts say the process has had a positive effect, galvanising staff to strive for better care. This is partly because the review process, which was intended to be supportive, talked about the elements of care that really matter to staff – one nursing director describes it as ‘the stuff that gets me up in the morning’. Concerns about nursing staff numbers featured
The Keogh review of hospitals with high mortality rates Following the publication of the Francis report into care failings at Stafford Hospital, NHS England medical director Sir Bruce Keogh was appointed by the government to conduct a review of the quality of care and treatment provided by NHS trusts with high death rates. A total of 14 hospital trusts were investigated as part of the review. The review process involved examining data, sending a rapid responsive review team into each trust and holding risk summits. In some cases, the team asked for issues to be addressed immediately, such as staff being expected to work 12 days in a row. When the review reports were published in July, all but three of the trusts – Colchester, Dudley and Blackpool – were placed in special measures. They will face monitoring against action plans and a further review within the year. Ultimately, their boards could be
NURSING STANDARD
dismissed or they could be placed in special administration and broken up. Last month, health secretary Jeremy Hunt announced that each of the 11 trusts under special measures will also be required to enter into a partnership with a high-performing trust. Leaders from the high-performing hospitals will work with the 11 trusts to help them improve and escape special measures. Meanwhile, the foundation trusts among the 11 will have their freedom to operate as an autonomous organisation suspended. The capability of leaders at all 11 trusts is under review and managers will be removed if they are seen to be holding back progress. Each of the 11 trusts will also have an improvement director, who will monitor improvement. Mr Hunt said he was confident that support from ‘inspiring NHS leaders’ would ‘get these hospitals out of special measures and on the road to recovery’.
in several reports, along with the ability to deliver quality care. And, although the trust reviews found many problem areas, they were often issues that nurses were already aware of and that directors of nursing had been trying to address. Brendan Brown, director of nursing at Burton Hospitals NHS Foundation Trust, says the review highlighted that the work they had been planning was on the right track. ‘My staff did me proud,’ he adds. ‘It has given us an impetus to get on.’ Karen Dunderdale, director of nursing at Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, says: ‘It was incredibly reassuring. It gave us confi dence that the improvements we were seeing in nursing were going in the right direction.’ The reviews increased the pace of change at many organisations. Plans for improvements are being completed in a matter of weeks, rather than months. Inevitably, however, this has put pressure on the small number of senior staff who can lead such initiatives. Boards and commissioners have been persuaded of the need for investment, especially in nursing staff. ‘We have to be realistic about the fi nancial situation, but it is about doing the things that are must-dos,’ says Dilly Wilkinson, deputy director of nursing at the George Eliot Hospital NHS Trust in Nuneaton,
october 23 :: vol 28 no 8 :: 2013 23
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 24, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
which is recruiting more nurses. ‘Some things have to be done.’ Many trusts’ responses to the review have included a decision to increase nursing numbers. Although some trusts did not report low staffing numbers initially, as the review process dug deeper it became clear that the figures reported at board level did not always tally with the experience on wards. At Sherwood Forest Hospitals NHS Foundation Trust, executive director of nursing and quality Susan Bowler has been carrying out a nursing review that will be presented to the trust’s board. She believes it will lead to a substantial increase in spending on nurses – the Keogh review identified nurse staffing at night as a particular issue. At United Lincolnshire Hospitals NHS Trust, interim director of nursing Eiri Jones says she felt there was a shortfall in nursing numbers when she was appointed a year ago. Additional investment of £7 million over two years has now been agreed. ‘Keogh said that we needed to increase nursing numbers faster. Together with our clinical commissioning group, we are doing this,’ she says. The trust now aims to have a ratio of one nurse to six or seven patients during the day, and one to nine or ten at night. The extra funding will pay for about 100 extra nurses. The trust has recruited 165 nurses
Recruitment
Basildon and Thurrock University Hospitals NHS Foundation Trust has already filled most of the additional 200 nursing posts it concluded it needed. It has also created a clinical sister post to focus on consistent and standardised practice on wards. Many of the trusts recognise that working with universities and encouraging nurses to return to practice will need to be part of a sustainable solution to recruitment. United Lincolnshire is working with the University of Lincoln, which has recently launched an adult nursing course. At George Eliot, changes to the recruitment process seem to be bearing fruit – applicants are invited into the hospital for a day and values are emphasised. Trusts are examining skill mix and the way staff numbers are linked to demand during the course of a day and week.
24 october 23 :: vol 28 no 8 :: 2013
NATHAN CLARKE
Basildon and Thurrock University Hospitals Buckinghamshire Healthcare Burton Hospitals East Lancashire Hospitals George Eliot Hospital Medway North Cumbria University Hospitals Northern Lincolnshire and Goole Hospitals Sherwood Forest Hospitals Tameside Hospital United Lincolnshire Hospitals
since April, but many of these are replacements for retiring staff. The challenge is finding new staff. Historically, some of the trusts involved in the Keogh review have had difficulties recruiting – geographical and professional isolation is a theme in the Keogh report. A number of trusts are looking to recruit workers from Spain and Portugal. There is an existing Portuguese population in Boston, where United Lincolnshire runs the Pilgrim Hospital. Ms Jones hopes this will be a draw as it recruits in Portugal. Medway NHS Foundation Trust, which was not criticised for its staffing levels, is spending an extra £1.6 million on nurses and £700,000 on midwives to improve ratios. It, too, is looking to recruit abroad.
SUMMARY
The 11 NHS trusts on ‘special measures’
Chief nurse at Medway NHS Foundation Trust Steve Hams: ‘We welcomed the Keogh review.’ He is pictured with head of nursing Jayne Gray (centre) and deputy chief nurse Ursula Clarke
A review of NHS trusts with high mortality rates resulted in 11 trusts being placed in special measures. This means they must improve or face being broken up or having their boards dismissed. Despite this, and the pressure of being under the media spotlight, many nurses in the 11 trusts have found the process energising. Author Alison Moore is a freelance journalist
United Lincolnshire has an assurance process in place, which ensures each ward has the right number of staff for its beds – and, if necessary, the number of beds will be reduced. The trust is also planning annual reviews of its nursing needs to inform workforce and financial planning. Maintaining staff morale is vital. Ms Jones from United Lincolnshire identifies fast results and good communication as important. ‘We are used to being under the spotlight, but there is the potential for it to be demoralising for staff. We do our best to ensure staff know that there are good things too.’ At Sherwood Forest Hospitals NHS Foundation Trust, staff coped well with the Keogh review team – but then they had a Care Quality Commission inspection
NURSING STANDARD
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 24, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
‘We found the revieW process motivating’
immediately afterwards, which affected morale. Many of the trusts are now talking about transparency, openness, listening and raising concerns – however, not all of the 11 trusts approached were willing to be interviewed for this article.
Staff feedback
East Lancashire Hospitals NHS Trust says that two days of ‘listening events’ provided it with feedback from staff that will inform its nursing and midwifery strategy. At Sherwood Forest, quality is now predominant on the board agenda. Northern Lincolnshire and Goole has looked at care of the deteriorating patient and improving the use of early warning scores, as well as preventing falls.
NURSING STANDARD
A number of the trusts have seen changes in nursing leadership in the past 12 months, and the Keogh review has emphasised the importance of clinical leaders. At East Lancashire Hospitals NHS Trust, the acting director of nursing is planning ‘back to the floor Fridays’ for herself and her deputies, so they can experience clinical practice on the front line. At Medway, chief nurse Steve Hams sees ‘authentic leaders’ as key to improving the engagement of the workforce. Part of his role, he says, is building confidence in the trust’s nurses, so they can aspire to great care. He also points out that small lapses in standards can spread rapidly. ‘If I see a piece of litter on the floor and ignore it, then I will have a dirty hospital,’ he says. ‘So, I pick it up’ NS
It would be natural to assume that the Keogh review process would be universally painful for trusts. But Steve Hams, the new chief nurse at Medway NHS Foundation Trust, insists it has ‘energised’ his staff and been far from negative. ‘We welcomed the Keogh review team with open arms and found the process motivating,’ he says. Part of the reason may be because the Keogh teams have looked at issues that matter to nurses, including staffing numbers and various aspects of care. ‘It probably reinforced what staff had been feeling. It validated their concerns and has created a great deal of energy in the organisation to get it right and get us off the naughty step,’ adds Mr Hams. Since the Keogh report was published, the trust has launched a ‘reboot’ initiative that encourages staff to raise and address problems, without having to seek permission. By the end of the first week of the initiative, all patients were being nursed in their specialty area, which was a major achievement. The trust was also more successful in discharging patients who are clinically able to leave, but are prevented by non-clinical reasons. But it is as much about raising confidence among staff as solving specific problems. Some staff were used as ‘JDIs’ – ‘just do its’, a cadre of enthusiastic go-getters who were prepared to cut through bureaucracy to get things done and improve care. ‘Back-office’ staff, who would not normally have contact with patients, spent time on the front line to see the difference that good care makes. The enthusiasm was palpable, but Mr Hams wants to see it sustained. Realistically, the exercise might need to be repeated every quarter, he suggests. october 23 :: vol 28 no 8 :: 2013 25
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 24, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
