July 2013

toby-with-staff67% of patients we admit as inpatients would be extremely likely “recommend our hospital to friends or family” with another 28% likely to.  Though many tell our healthcare assistants and nurses what a curious question they find this, as they wish no ill health on those they love!  Our annual staff survey shows that 50% would also commend what we do here, with the majority of the less complimentary being non-clinicians (a pattern we are working to understand and respond to).

I am writing about this because I think we are at a time when confidence and trust in our NHS is an issue.  And of course confidence and trust are critical matters in healthcare, not merely because people pay for our service through their taxes and National Insurance, but more importantly because any visit to a consulting or emergency room involves an exercise of trust – in the expertise and wisdom of the clinicians one is seeing and the system that surrounds them.  So expectations matter.  We can only do our clinical work against a belief not just that we act ethically at all times in recommending treatment, or indeed no treatment, but also that those people wearing our badge on their lapel have the confidence of the organisation, the Board of Directors and those of us accountable for the public’s trust.

Leadership-Conference011-250x2501In that context, there are some important adaptations being made within Sandwell andWest Birminghamin how we work, building on a tradition of candour which we are proud of here.  From September, the Chairman, Richard Samuda has moved our board meeting in public earlier in the day so that we can get better attendance, but also to reflect a commitment from our Board that we will do our business in public unless there is an overwhelming reason not to do so.  Last month we had, deeply regrettably, a Never event in our eye theatres.  The patient is unharmed and very content with their care.  Nonetheless, we made an avoidable mistake.  The clinician accountable for that service joined our public Board meeting so that we could debate immediately what went awry and how we prevent that occurring in the future.  In that case, but also in a great deal of what I see in healthcare, the critical difference between excellence and error is often the quality of teamwork that we have in place.

Nowhere was that idea of teamwork excellence better illustrated for me than in our recent process to select our “Beacon” services.  These are our top performers.  This was a participative process of submitting bids for accreditation, championed by Roger Stedman, our medical director.  In the end, eighteen teams put themselves forward, six made the all-star finale, and the top three were selected.  We chose three contrasting award winners this year:

– Our gastroenterology team, who work across site and within the community, have delivered a huge reduction in hospital attendance among our patients by providing care in different ways, and are at the forefront of our public health agenda (which I wrote about on this website last month)

– Our gynae-oncology team, who are, of course, the regional cancer centre, and who can now demonstrate the best mortality results of any such unit in theUK.  Combining service and research this is a team bringing the very best of the NHS to the heart of this community.

– Our breast surgery team, past winners of national awards for innovation and efficiency, who can truly demonstrate that a single-site service does not mean a disconnect with local partners.  They have cut avoidable admissions, offer a genuinely year-round service without delay, and find time to have the largest research trial enrolment in their specialty in theWest Midlands.

7,500 colleagues are proud of these teams, and I hope you share their excitement at their selection.  In October our annual awards ceremony will give us another chance to identify the best of what we do and to encourage everyone here to learn from those teams.

From September, the way we report our “performance” will change ever-so slightly.  The same board sub-committee, chaired by one of our non-executive team, Olwen Dutton, will oversee assurance to the Board, and to the public, on both quality and safety, and so-called performance, which in the NHS usually means the matters on which external regulators assess how we are doing.  This integration, which will be reflected in what information we publish internally and externally, will remove any perception that we have competing agendas in place – one for quality care, and one for system compliance.  I should be clear that after 110 days here, I observe no such competition in our Trust, but should there be a tension my view is that it is best handled in one setting so the debate can be real.  As of course it is for teams managing services at the frontline.

If you do scrutinise our Board papers, or read our Quality Account 2012-13, you will find a focus on our mortality information.  I was encouraged when I joined SWBH in April to find that we already have a group meeting monthly focused on the meaning of this data.  At a headline level we do well – our latest Trustwide position is 95.5 on SHMI.  Of course, the measure moves to reflect countrywide expectations, not least as medicine changes, and so we need to keep working on what more we can do to improve our quality.  In quarter one the big emphasis for us has been on recognising and treating sepsis, which we see as the largest area where action in our Trust could improve patients’ chances of rapid and significant recovery from ill health.

If you have been reading the Keogh report or indeed the Francis enquiry’s more recent report on Mid Staffs, you will be aware that mortality information can often give rise to ‘red flags’ that transpire to be of no concern.  That is the great cultural challenge we face (and will meet) to look every time in the expectation that there may be a problem, even if the last few times, detailed enquiry has found no cause for alarm.  Likewise, we need to be vigilant that expectations of someone passing away, and plans to make that passing the one sought by our patient, do not lead to flawed data.  We track in hospital deaths through a system of peer review and also review the placing of any patient on the supported care pathway.  We are working hard to make sure that all of our clinicians are familiar with the system, rules and expectations we have set around not just patient but family involvement in decision making.

My sense is that people understand that hospitals are places of risk, as well as places that they rightly expect to be safe within.  That is one of the reasons we work hard to only admit people who have to be in a hospital bed.  Over coming years we want to reduce our reliance on beds and treat more people at home.  In making moves towards that aim, we will rely on technology (as we do currently to remotely monitor 900 cardiac patients via our telephone system), on our own clinicians visiting people at home (we have not only over 170  district nurses but also a range of super-specialist teams who work beyond the walls of our hospitals), but – and this is critical if we are to have a sustainable change in how we provide care – we also need to make sure that we can rely upon and link coherently with others in the health and social care system, and with volunteers and ‘third sector’ groups as well.  I had the pleasure of attending our latest Foundation Trust members event a fortnight ago, and well understand the concern expressed there that this narrative of more community provision sounds plausible in theory, but has to be in place in practice, before we try and reduce the size of hospital based services.  That sense of trust is why, in part, we are accelerating our change plan to expand services at Rowley Regis hospital over coming months.  It is important we are not ideological about the direction of change, and where our ambitions cannot yet be realised, we must offer a “plan B” to keep services safe – which is why over the next two months in preparation for winter 2013, we will open additional beds, specifically to care for people who need care at home from various agencies but who otherwise would be in an acute specialist medical environment because those services are not yet in place.

These themes of safety, of trust, of planning for the long term future, but of keeping a relentless eye on the reality of today’s care, are the pre-occupation of the whole executive and Board.  They are also the work of the wider leadership team across our seven clinical groups.  We are a large organisation, and increasingly it will be the role of those clinicians and managers to drive forward improvements and innovations in their services.  My task as Chief Executive is to support them to do that and to make sure that the infrastructure that they have is sufficient to make the changes our patients want and deserve.  That means I am focusing on our leadership culture, the information that teams have to work with, the pace of decision making which can get slowed in complex systems that have to collaborate to succeed, and on making sure that our enthusiasm for change does not neglect or override the many good things that we need to conserve, because they work and are valued.

Over coming months, both colleagues inside the organisation, and patients, families and members, will find us making more and more data available, not only about our change plans but about our results.  There are some great examples of that at the entrances to each of our wards, but there are also good examples regionally of how Trusts have offered great data to patients before their admission on what to expect and what other patients thought.  In addition, we are part of one NHS in which that data is increasingly being published – the recent vascular surgery mortality data illustrates why last year services were rationalised to UHB.  The forthcoming surgical data release will illustrate the quality of much of what we do, as well as the need always to make sure data quality is part of what we do well (our poor data quality in colorectal services will doubtless occasion some press comment when the national league table is published – let me in be clear in advance that myself and our Board are fully reassured about our high calibre colorectal service.  This is a straightforward data entry error.  All the more frustrating as this is one of our best services, moving into the community through our faecal incontinence team, and undertaking among the largest volume of research of any surgical unit in the NHS).

This website will be one way in which we try and make information more readily available over time.  It is in the process of changing itself, to make sure that the content is up to date and increasingly provides the right balance of comment and facts.  If you have ideas about what you would find useful on the site, do get in touch with us.  And of course if you have questions for me, either about what I discuss here, or more generally, please feel free to email me or contact my office team – tobylewis@nhs.net

Toby Lewis – Chief Executive