My first observations when I first joined the Trust, and my hopes and fears for the future at University Hospitals of Morecambe Bay NHS Foundation Trust
A series of personal blog posts sharing my own views, rather than those of the Trust.
I am very fortunate that both my parents are alive and reasonably well. They have asked me the same question all of my life and continue to ask it today. “Jackie what are your hopes and fears?” This question can be asked in relation to anything, and over the last few weeks, I have found myself trying to answer it in relation to my world of work and the organisation I serve.
The reason for this I think, is that University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT) is at a crossroads in its journey of improvement, with each road offering a different possibility. This is by no means unique, as all NHS organisations grapple with their future in a context of limited finances, growing demand and the possibilities within the NHS “Five Year forward View”.
The current position is all the more stark when I think about the situation when I joined the Trust three years ago. Most NHS staff know something about UHMBT, and when I joined, we were in the regional and national media almost daily. The issues leading to the Report of the Morecambe Bay Investigation (often referred to as the Kirkup Report), outlined devastating and far reaching failures across a decade for women, babies, families and their loved ones, and painted a glaring picture of poor care. There were also failures in other services which were well reported by both key NHS regulators at the time.
The Trust was operating on crumbling foundations. It had a poor culture, disengaged staff, and less than ideal relationships with partner organisations, together with a nervous and understandably distrusting local population who recognised they needed their local health provision to be of a high quality. At this time, the strategy of the Trust was to pursue Foundation Trust status, appearing to put money above quality and seeking to grow income and services in a way that was common place in the past.
It was very clear to me that this simply wasn’t sustainable and was the reason the Trust had been failing for some time. But what was the answer?
It wasn’t easy to see the solution, and there certainly wasn’t an easy answer. A solution had to be found, and this was one of the reasons for me taking the job at the time.
The local communities around Barrow-in-Furness, through to Kendal and along the coast to Lancaster and Morecambe needed high quality health care provision. Their requirements were very different, with a population size of around 360,000, spread across a wide area with varying levels of deprivation, morbidity and mortality. For those people who don’t know the geography – here’s a few facts. The Trust covers around 1,000 square miles. The Bay, as the crow flies is a short distance, but traversing across the patch by road is a different story. Morecambe Bay is actually the second largest Bay in Britain after the Wash. We have five sites – two main DGH sites (Barrow and Lancaster) both with A&E and a full range of services, one intermediate care Hospital at Kendal (Westmorland General Hospital), and two outpatient sites located in Ulverston and Morecambe.
Figure 1: Morecambe Bay and UHMBT sites
This pretty unique geography presents us with a number of challenges. We have to think and plan our services carefully to make sure our staff and the many teams are able to deliver consistent standards across the area. Many clinical staff travel between the sites, which can take up to one and half hours, and much more with traffic delays. So there are many logistical issues we juggle in order to provide care locally.
There is also the challenge that the costs of providing healthcare is funded through a national tariff which is based on an ‘average’ price for each service. This average price typically applies to trusts with half the number of sites and a much greater population and activity using those sites.
Given these fairly unique circumstances, it is not difficult to see why following the lines of the previous strategy was fundamentally flawed.
In seeking the answers to remedy past failure, a number of things were obvious. In no particular order, they included:
- Engagement of staff and our populations was key and we had to find a way of achieving this;
- The way of funding the acute hospital care in Morecambe Bay wasn’t working – some sort of price modification was required in the first instance;
- The “Bay Pound” in healthcare terms wasn’t being invested wisely and we needed to look to integrating services to improve efficiency and drive up quality. Four Foundation trusts, two Clinical Commissioning Groups, two emerging GP federations and a myriad of voluntary sector organisations, together with local authority provision, needed to work better, together. We needed to join services up;
- Isolated units such as the obstetric unit in Barrow-in-Furness needed to look to larger hospitals with a greater spread of case mix and volumes of activity to constantly learn and improve;
- Clinicians in remote locations weren’t always looking outwards and refreshing their skills and knowledge, which can lead to deteriorating standards (and culture). Partnering with larger trusts and specialist units was key.
“It was never about an organisation or position as CEO. We were uncompromising that the promise of leaving a legacy for the population around Morecambe Bay trumped any other concern or viewpoint.”
Finding a way through those early days was tough. We needed to rebuild a Trust Board, as well as the wider leadership and support teams and begin to establish trust with our staff, public and partners – these were all on the top of my priority list. There were multiple action plans which typically flow from intense regulation. Maintaining a grip on today, whilst building a vision of the future, was difficult, but essential if we were to find a long term solution. Setting out a framework under the headings of ‘stabilisation’, ‘transition’ and ‘transformation’ gave staff and the public a road map of the steps we were taking to improve services. This also enabled us to work through the short term fixes, whilst beginning the work which would lead us out of our current situation.
Figure 2: The UHMBT Three Step approach to transformation
‘Better care Together’ was born. It took a little time to realise that working on a strategy which focused solely on our acute Trust wouldn’t help. We needed to think about the provision across all sectors. The frailty of the acute sector was also apparent in areas of community services, primary care and mental health. Difficulty with recruitment and sustaining services within financial and operational silos was a distinct part of the problem.
There is something about being stood on a ‘burning platform’ which encourages action – to move off it and quickly! Many of the services across the Bay were struggling which gave us a common purpose. There is a danger in this short piece that I make this sound easy. It wasn’t! As partners, we sometimes disagreed, and pressures of regulation and media intensity brought about the inevitable tensions. However, I can say in retrospect that we never gave up and stuck with the development of an integrated service wrapped around our communities and the patients we were all here to serve. When I reflect on past experience, this fundamental position from all parties made the difference. It was never about an organisation or position as CEO. We were uncompromising that the promise of leaving a legacy for the population around Morecambe Bay trumped any other concern or viewpoint.
By the time the NHS Five Year Forward View was launched, we had developed Better Care Together with our commissioner and partner organisations, a strategy for care across the Bay, along with a more detailed, two year delivery plan, and business case for much needed capital and revenue investment. There are times in life when the planets align, and this was one of those times. Suddenly the policy context made our intentions and plans seem increasingly possible.
Coming back then to hopes and fears…
I have concentrated my efforts on ways to engage staff and support them to lead the improvements we so desperately needed. There hasn’t been one single method of doing this, rather a whole series of actions from communicating widely and well, for example, writing a Friday Message every week, to appointing leaders who we knew would live and work by our values.
Listening into Action (LiA) has ignited the passion of frontline staff and led to some amazing achievements. A constant theme I talk about is behaviors and how we might create a better culture. I know from feedback from staff that they appreciate this explicit permission not to tolerate poor behaviors. I know, and there is growing evidence, that staff are feeling more motivated and involved. There is also evidence that this is contributing to an improvement in our patient outcomes and satisfaction.
I hope we have reached a tipping point where this is just how we work and get things done now. There is now an ‘army’ of like-minded staff across the Trust who are taking on the initiative and ownership for improvement, and I know this will continue.
I hope we have now rebuilt some of the trust which was lost with our public and the patients who use our services. We know through the feedback mechanisms we have built that there is a growing confidence in the quality of care provided, and also a confidence that if we are given negative feedback, that this is acted upon and we put things right. Being open and honest when we get things wrong is the cornerstone of rebuilding trust.
I hope that the bravery and courage shown from the Government, the arm’s length bodies, and all connected with the creation of the New Models of Care Programme, continues. I recognise that in the NHS – a body which is highly regulated – taking decisions to reverse decades of thinking can seem risky. There has been an increasing tendency to wrap bureaucratic process around decisions in the hope this will lead to the right answer. The fact is that doing nothing, particularly in the context of Morecambe Bay, simply is not an option. Allowing clinicians to work together across organisational boundaries and design a better way of providing healthcare is the approach we have taken in Morecambe Bay. As the plans developed, it was clear to me that the solutions were not rocket science, but they made sense and would improve care for our patients. In the past, organisational boundaries had got in the way of doing the right things for patients.
We are about to move into the next stage of Better Care Together. We now have the blue print, and know how services will look differently to improve care in the future. Sure we haven’t got the detail for every service line yet, but the building blocks are in place. We will, of course, need to reflect at each and every stage in this journey and constantly adjust our plans as we receive feedback from patients, staff and partners.
Rather than operating within a financial envelope of ‘buckets’ of a few hundred million pounds, we hope to create a shared budget which is much larger. Partners are not under any illusion, there will be difficult decisions to make to live within our means. The difference will be that we all have a collective ‘skin in the game’, including of course our patients. We are also beginning to consider the governance arrangements to oversee an Accountable Care Organisation (ACO). On the ground, our teams across acute, community, primary, mental health and social care are beginning to work together in communities. 18 months ago, they didn’t all know one another! More importantly, we are engaging with our communities and they are shaping the future of their services with us, Check out the work happening in Millom.
The current financial pressures are leading various parts of the NHS architecture to get increasingly instructive – promoting a one-size-fits-all approach. I hope this is questioned where appropriate. In the case of Morecambe Bay, it will take a number of years for the financial picture to improve, and for us to be sure it has been sustained. I am absolutely clear though that the measures we are taking will improve return on the ‘Bay Pound’. Furthermore, the approach will make sure our clinicians have ownership and influence on the way the resources work and are used locally.
Finding our way through the next stage in our journey will be just as challenging as the last. We must maintain the improvements we have made, and continue to develop our plans for the future. The moves needed to create a new system of care delivery locally are complex. Health and care partners across Morecambe Bay – I call them the Bay Partners – will need to stand shoulder to shoulder with our patients and public as we wrap our services around them and create a resilience not seen in recent times. We will need to communicate and share our plans in different forums, and in different ways, so that staff and the public can engage with THEIR health and care services.
Reflecting on my hopes and fears is my way of sharing how our plans are shaping up and the risks as we move forward. I hope you find it useful and of interest? Of course the analysis, modelling and various calculations and forecasts to support the business case and each stage in it, are vital. The stakes are high and getting it wrong is not an option. However, there is also sense in knowing what your gut and your heart is telling you – instinctively, I think many of the answers can be found here. Doing the right thing above all else will keep us on the right path.