February 2015

February has been a big month for public involvement and engagement at the Trust, or it has been in my opinion.  We have kicked off the public meetings about changes in cardiac interventional care and acute emergency surgery that I wrote about here last month.  Meanwhile, a CCG led process on the long term model for urgent care is beginning. That is welcome.  Right Care, Right Here (RCRH) fixes three parts of a system, with the major A&E at Midland Met, our eye casualty remaining in BMEC, and the creation of the big urgent care centre at Sandwell.  But these resources will only work if the wider system of GP out of hours and primary care emergency access works well 7 days a week and 365 days a year.  So it is important we find a simple area-wide approach, which has public support.  Whatever the A&Es can do to signpost people into that system, we are pledged to do.  Especially if those alternatives offer the continuity of care that most patients tell us they want.  Of course, we work in an area where some communities are motivated by different prices for prescribed medicines between sectors, or where GP medicine is not part of their cultural tradition.  So it is vital our system is fit for purpose and does not just rely on “educating” users – many of whom make much more sophisticated use of the current arrangements than policy makers sometimes assume. Finally (and I promise this flurry of engagement is not general election related) the Trust led work on Rowley Regis has started  – see our survey here.  The hospital has a big part in our future, but some choices about the spare space are now needed.  A good problem to have, and the advocacy of local politicians of all parties in promoting the debate is very welcome.  So much has changed on the site in the last two years: ward beds have trebled; clinic volumes leapt; that we have a chance to meet the RCRH vision very soon.

I am proud of the fact that the Trust – distinctively – continues to meet almost all of the core standards set out in the NHS constitution: For short diagnostic waits, cancer care, planned treatment, and low infection rates.  Sadly after a good end to January, February has again seen us struggling to match the emergency care standard, as discharge rates have fallen alarmingly.  With delayed transfers of care double the level of 2013/14, we face an uphill battle to manage a rising volume of admission through fewer ‘turning over’ beds.  I am convinced everyone in our system is trying their very best, but we have to be honest that our efforts are not yet succeeding.  We need a shared pace, a single drumbeat, a commitment to one measure of success – and at times that common cause does not drive every behaviour.  In the year ahead we will be working with fewer beds, so now is definitely the time to make the changes we need  in place.  It was clear when this month’s Board reviewed intermediate care, that our iCares and iBeds teams have done a fantastic job supporting increasingly unwell patients – and though it is very early days the CCG’s Own Bed Instead project may be a useful addition to that approach.

Last autumn we made some difficult workforce changes in parts of the Trust, and consultation on the second phase of that work will now commence this April.  I am genuinely delighted that we have kept our redeployment promise with over 150 colleagues finding new roles.  And kept our listening promise, with almost one in four schemes amended during consultation, and some, such as changes to overnight chaplaincy stood down altogether.  It is difficult for all of us when longstanding or recent employees have to change job roles.  There is more we can do to make sure all parts of the Trust are focused on developing talent internally – and our training budget supports someone’s next role with us not just the current one.  There is no question that the psychological contract with employees is changing, not just at our Trust but across the service.  Old certainties are adapting, and we need to be very clear what the promise is to those staying with us.  Of course the adage rings true: People join an organisation and leave a line manager – so the development of our management skills is among the most vital parts of what we do, and a big part of Raffaela Goodby’s role as the Trust’s first Board level workforce director for over six years.

Time now for mention of Midland Metropolitan, without which silence gets over-interpreted in some parts.  Our new hospital is due in 2018 on Grove Lane and the site is now almost demolished to slab – with underground testing and remediation underway.  I know that for some local people the new build is the promise that never delivers, but we are now about 202 weeks away from success.  The timescale makes me remember how precious each week is in securing contract signature, design approval from the council, and staff acclimatisation to the new site.  We will have the right adjacencies for modern medicine, and standard ward layouts for safety.  But it will be how we use these assets which will drive more improvement in our already low infection rates and better than expected mortality rates.  Certainly in 2016 the countdown starts in earnest as to how teams will work in our seven-day care model, technology enabled of course.  Every change we make now has a Midland Met dimension to it, done with an eye to the medium-term – well, near-term in honesty.  Of course, I get asked a fair bit if we can afford it.  Three answers come to mind; there is no “do nothing” option, so this is the best choice we have; we can afford it and the annual cost is largely met through efficiencies only possible because of it; but it is a tight call.  The Trust is being reshaped from a hospitals Trust into an integrated care organisation, and those holding the procurement purse strings need to recognise the fine margins involved.  Changes in our system cannot be dictated by one new hospital, but each change must take account of the biggest NHS change here for sixty plus years.  Everyone wants their actions to help but the litmus test is whether those plans help us to reshape and redeploy our workforce, creating home-based care teams connected both to general practice and acute care, and tackling underlying health needs for 2030, when the new build will be too small unless we see a change in patterns of both need and use.

In January I celebrated here our Never Events one year anniversary.  This last week marked over 350 days without a pressure ulcer on four of our surgical wards.  Another big achievement, with credit due to teams on both acute sites who have worked to change practices to succeed.  To some degree celebrating safety should be unnecessary. These are baseline standards we want to meet consistently well.  But healthcare internationally sees harm come to perhaps one in ten patients.  So our task is to try and drive out error and mistakes where we can, through a mix of standardisation with what works best and innovation about what might work better.  There are definitely areas where we have further to go – medicines security needs improvement, we have a handful of admissions that go without MRSA screening, some lower acuity emergency surgical patients wait too long.  But I hope our openness about these issues is refreshing and reassuring.  The Board and wider leadership cannot claim to know all of the weaknesses in our care, but we are constantly on the lookout for room for improvement.  External assurance comes and goes, but the lesson from places like Stafford General, and perhaps the forthcoming Morecombe Bay report, is that local staff, leaders, and patients are the best guardians of standards of care – if that spirit of brutal honesty is in place, combined with a confidence that we will keep trying until we succeed.  I hope we have that.  I sense we largely do.