September 2015

With August fading to memory, winter plans due in, and flu jab season just days away, I am reflecting on what we are trying to achieve at the Trust in September, October and November.  These are months in which we promised our CQC improvement plan would begin to grip, months in which we get a sense of whether our changes to care flows will see us safely through winter, and months in which how we book theatre and outpatient care changes completely.  As that implies the ask of local leaders is deep and wide.  Our job as a Board is to help, to encourage, and to protect those people from the incessant stream of external demands on their time.  Whichever change project I am describing it rests on that cohort of leaders, and their success depends on the management of people.  Most of the time we do that well, but the preoccupation we have is with making that consistent.  You can see in our appraisal data, in our staff survey, in our sickness rates and absence management practices, the difference made by great local managers and leaders.  That has to be the mortar that holds together what we are trying to build here at the Trust.

Our room for improvement work has seen real change internally.  Quality improvement half days (QIHDs) bring together almost 2000 staff monthly to talk and plan for better care.  That should give us the chance to learn well across the organisation, and having changed incident reporting systems to make them even more responsive there is a sense that we are making progress.  Our staff survey work on QIHDs is overwhelmingly positive, and staff themselves have put forward a huge list of changes they plan to make through that mechanism.  I was pleased that external bodies continue to comment on how open we are when things go awry.  That too is a symbol of a healthy culture – I have had feedback from incoming trainee doctors that our Trust seems to them (as people who change Trust by rotation) distinctively committed to great communication and listening too.  It is 50 days plus now without a never event, and I was shown last week in Theatres the on-the-ground changes made to try and prevent past errors occurring.  In the next few weeks our new locking systems arrive for security of medicines.  And of course we continue to focus on cleanliness and infection, with another outside invited inspection in a fortnight’s time to complement the visits myself and non executive colleagues are making.  Ward documentation has been reviewed top to bottom and I hope that by November we can celebrate much more personalised local care planning, and the documentation of those fine intentions.  Ten out of ten, our set of ten patient safety standards, is linked to that and to my theme of consistency, and we are trying yet again to get that spirit into each of our ward clinical teams.  In October nurse vacancies will hit their lowest level here in three years plus, and that should create space and time to really bed down the standards on each ward that our patients have the right to expect.

Day to day delivery is the key to consistency, but sometimes we need to make apparently big changes to achieve improvement.  So in August we switched to single site cardiology, or rather single site interventional cardiology at City Hospital.  A leap in numbers to be treated perhaps reflected the well known halo effect of a new service (something we need to watch for with the new Midland Met Hospital).  And heroic effort by the cardiology and imaging teams saw us through.  This month, September, we host the regional research conference for stroke – two and a half years on from the single site move to Sandwell.  This is definitely a chance to celebrate the service gains made through that move but also to commit ourselves to the growth in research output we are seeking.  The Institute of Translational Medicine battle bus gets an outing from UHB to help us, as we aim to create a research focus around our Black Country Alliance.  We are very much looking to develop specialist services on our patch, both in areas of existing strength like rheumatology and in areas of real need like oncology and nephrology.  As a Trust we are one of few locally meeting waiting time expectations set nationally.  But that good work depends on partnerships with, among others, HEFT and UHB.  And the volume of cancer onset in our population continues to grow, at a pace outstripping resources and manpower.  We continue to invest in pathology and imaging, and very much hope that the recent national cancer plan will give the context in which to reach long term agreements for funding in this vital area.  Like much of medicine, cancer care will change over the next decade.  The development of genetic medicine will change what we do and how we do it, which is why we form part of the 100000 genomes programme across the West Midlands.  Increasingly we ought to be better able to anticipate potential ill health, as well as to design very targeted therapies on a per patient basis.

National policy attention, media focus, and our effort (not in that order of sequence) remains focused on how tackle temporary staffing safety and cost.  As a Trust we have long had high vacancy rates and high sickness rates.  We are making progress with the former, as nurse recruitment improves and we fill our radiography vacancies.  We continue to have hard to fill roles and some peaks of sickness.  The frustration is that we know what works to tackle short term sickness, as I have written here before.  We are making progress with making that happen everywhere, but too slowly.  If someone is repeatedly away from work for short periods, we need to intervene.  Either with occupational health help, or potentially with conduct proceedings.   Once we have done that we will see what residual issue remains, although at any given time we have perhaps 100 staff away from work for between a month and three, often for health treatment.  Sometimes, even then, we could be smarter about managed returns to work.  Our agency drive starts with filling posts, and then moves on to making it both easier and more attractive to join our in house bank.  An external agency has to be a last resort, and better rostering should permit smarter forward planning to address issues.  However, working until 2018 across two acute sites we will continue to have pressures, which after all are part of what drives us to want a single emergency site.

In the midst of these big issues remain smaller frustrations and, tackling them, welcome local projects and initiatives.  We are trying to cut food waste by both through using simpler ordering models for our patients to reduce it, and then bringing in an external firm to make use of what we can’t.  At the same time our greenhouse project may begin to grow some food stuff on site.  Sandwell is just starting to get on site wifi, which we introduced into City late last year.  Increasingly we want to try and use app and video technology both to support patient care and involve staff.  Leaflets can help, and it is good to see more in more languages and formats, but we can really bring a subject to life on screen.  And it is perhaps easier to keep things up to date.  As I wrote about last time this autumn will see us change our outpatient bookings systems.  We will be looking to agree dates with people, rather than issue them, often late, and then reorganise them.  Of course, we will create new and different issues in making changes and so we will need to be alert to those issues and solve them as we work through the change.  Cutting DNA rates and reducing the waste and risk of rescheduling are our aim.  During this year, originally by October, we said we would hit a six week maximum clinic wait, and in some specialties that will require significant change in the weeks ahead.  Change needs team work not harder work, and we have some wonderful teams who are stepping up to that challenge.  Our staff awards for 2015 take place in a few short weeks and I very much hope that our 2016 vintage are filled with the successful outcomes of this massive endeavour.