How do failing NHS trusts get back to delivering high-quality care? The answer, a new study suggests, can involve emulating Dragons’ Den, the boss popping in at 3am – and staff doing less rather than more.
A report from NHS Providers sets out in detail how 11 trusts providing acute, ambulance and mental health care in England have used a negative rating from the Care Quality Commission as the catalyst for a turnaround in their fortunes.
The 11 trusts’ approaches were all different. But the lessons learned from how they shook things up and ultimately regained a good CQC assessment for their efforts offer valuable insights into how quality and safety of care can be transformed despite underfunding and staff shortages.
The report, called Providers Deliver, points out how 68% of trusts were rated “requires improvement” or “inadequate” by the CQC in 2014 – but now 59% are rated “good” or “outstanding”. Similarly, over the last two years, the number of trusts deemed “good” has risen from 96 to 107 – and those rated “outstanding” from 14 to 24.
In all, 36 trusts have been put into “special measures” since ministers and NHS national bodies created that regime in 2013 in response to the Mid Staffordshire care scandal. Ten remain in it, and are receiving help – from the NHS and often an outstanding trust that becomes their “buddy” – to help them overcome their problems.
But the other 26 have left special measures, on the say-so of the CQC’s chief inspector of hospitals, after pushing through a combination of clinical, organisational, staffing and behavioural changes.
So how has this widespread but largely unheralded revolution happened? How can a trust go from “requires improvement” to “outstanding”, in some cases after not much more than a year?
Leadership, innovation and staff are the three themes that recur throughout the report. A trust’s workforce emerge as the key driver of sometimes painful improvement.
Listening to ideas for change from staff and then empowering them to implement new ways of working appears to produce results. Bob Warnock, a senior clinical professional and physiotherapist at North Tees and Hartlepool trust, sums it up. “We realised the people on the frontline are our experts.”
Eschewing the NHS’s traditional “the bosses know best” approach and taking genuine heed of staff members’ views led to the trust establishing a frailty team to offer older people at risk of falling more help at home – and so reduce unnecessary admissions to its hospitals. It has also set up an integrated single point of access for those needing healthcare, social care or both. It’s a telephone service that people can ring to speak to health professionals – who then arrange the most suitable form of support from nurses, social workers and therapists.
The two innovations together led to a reduction in avoidable admissions – and a reduction in the delays patients experienced leaving hospital to receive social care and community rehabilitation. These delays had peaked at more than 1,000 days in October 2016, but were down to 200 days in October 2018.
The trust went from “requires improvement” to “good”. As did Chelsea and Westminster in London, which asked staff to put their ideas about how to improve care and services to the test in a Dragons’ Den-style competition. Angela Chick, a ward manager, and Ahlam Wynne, a specialist nurse, wanted to reduce the number of patients with swallowing problems who get pneumonia. They suggested introducing mouth care kits to the stroke ward – and helped the kit’s manufacturers to design one that hung over the side of a patient’s bed. It replaced the toothbrush or sponge that had previously helped them reduce high levels of bacteria – which can lead to pneumonia – in someone’s mouth.
Since then the amount the trust spends on antibiotics has dropped by 79%. Crucially, cases of hospital-acquired pneumonia have also dropped – down from 30 to 10 year on year – as have deaths from the infection, which are down from eight to two a year.
Taking steps to boost staff wellbeing also emerged as a key ingredient of success. With recruitment and retention their number one problem, trusts know that making their organisation a better place to work is a must.
Kingston trust in south London made staff welfare a key priority under new chief executive, Jo Farrar. “Our absolute focus as a board was on staff and that we treat and support staff in the best way we can so they can deliver the best care,” he says. That includes free sessions of yoga and pilates to help staff destress – and also free physiotherapy to help treat the painful musculoskeletal injuries that are common among hospital staff.
That, alongside listening and acting when nurses, midwives and allied health professionals warn that staffing levels in particular wards or areas of care are inadequate, has helped reduce its nurse vacancy rate to 6% – half the NHS average of 11%. And the trust went from “requires improvement” to an “outstanding” CQC rating.
Other examples of innovation in improving quality of care include the London Ambulance Service’s introduction of “mental health response cars”, in which vehicles containing a mental health nurse as well as a paramedic attend when the 999 call involves someone in mental health crisis. That has cut the number of such patients then taken to A&E from 53% to 19%. In a similar vein, the South Western Ambulance Service has helped more people who are terminally ill to have their wish of dying at home by training paramedics to recognise when someone is in their final hours. They can then arrange to keep them comfortable in their usual surroundings rather than a hospital.
Chris Hopson, the chief executive of NHS Providers, says: “Trusts are held accountable when they fall short. But we should also celebrate their successes, and promote understanding of approaches and ideas that could benefit patients across the NHS.”
