Professor Sir Mike Richards, Chief Inspector of Hospitals, Care Quality Commission, responds to our report, Organising care at the NHS front line, and discusses the role of regulators in addressing the issues it raises.
This presentation was recorded at our event Views from the front line: how can we improve hospital care? on 3 May 2017.
So the challenge I think that you threw out at the start Chris was that you’d been to Western Sussex which has been rated as outstanding and I want to explain why we’re rated as outstanding but at the same time why I said in my piece outstanding is not perfect. In fact you could say we ought to have a category of perfect but I’m quite sure I’m never going to award it. Mind you I am retiring in three months’ time so somebody might do in the future.
But why is Western Sussex actually in the top five percent of acute hospitals and that is because it provides consistent high quality patient centred care despite a lot of problems. The first place to acknowledge that there are these problems is Western Sussex. Is the environment perfect? No it damn well isn’t. Is the IT what it should be? No it isn’t, but despite that it is giving extremely good care.
How do we go about assessing that? Most of you I hope by now will know about the CQC‘s approach. For any service that we’re looking at, it doesn’t matter whether it was a general practice, a care home, an intensive care unit, we have five broad questions. Is it safe? Is it effective? Is it caring? Is it responsive to patient’s needs? Is it well led? We have then defined these five questions and there are myriad questions of course beneath that, but safe is are people protected from harm? Effective, actually are people made better and not just prevented from getting worse? Caring, the whole bit Michael that you were raising about compassion, about time, about listening to patients. Now we talk to patients to find out what they think. We observe what’s going on on wards, we look at patient survey data, we take all of that together. We find in general that compassion is alive and well in the NHS. There are exceptions to that and probably in any place there are occasional exceptions to that, we find some places where it really slips well below that. The responsive question is can you be seen at a time that’s convenient to you? Are you seen within the waiting time targets? All of those sorts of questions. Then our fifth question is about well led, because people like Michael West have done the work that really shows that services that are well led that predict the future as well as telling you what’s happening now and we have based our model of assessment of well led on his work.
So then when we go to an acute trust, and I’ll speak mostly about acute trusts, we look at eight different core services. We have to split the Trusts up in some ways and I’ll show you that in a moment. Right from the outset we were given a four point rating scale. That was the only thing that was actually a given when I started you have to use the same rating scale as Ofsted, outstanding, good, requires improvement and then inadequate and there’s a reason behind that and the reason is that if you have a five point scale the tendency is for people to be put in the middle one.
So we’ve now inspected all 238 Trusts that’s the acute, the mental health community, ambulance etc. What have we found? We have found vey wide variation and the important thing is we’ve found wide variation both within Trusts as well as between Trusts. So we have out of the 238 Trusts we’ve rated thirteen of them outstanding, but at the other end of the scale 31 Trusts total have been put into special measures. Quite a number of those have come out of special measures during the last three years and one of the comments that we made recently when we published our overview report on acute hospitals is about what we called the burning platform. The burning platform of the acute care model being unsustainable. Jane what you referred to as sludging up exactly that, and saying this model has to change, it needs to be transformed and that’s why, and I know that Sam Jones is in the audience, we need new models of care and we need much greater integration between primary care, hospitals, care homes etc.
Just want at this point to show you the variation that we have. So this is a real hospital it doesn’t matter where it is because it is quite a small DGH and it shows that what we do when we go in is we look at eight different core services, A&E, medicine, surgery, critical care, maternity, children etc, etc. We’ve given a special core service to end of life care because we think it’s been ignored in the past. Each one we rate on our four point scale as safe, effective, caring, responsive and well led and then we have rules for how we aggregate those and what’s typical about this is it’s the front end of the hospital that is really struggling. So the A&E is struggling, medical care is struggling, surgery and critical care. Actually much of the rest was doing alright. That is the transformation that we need in that acute care model.
Just to show the variation here this is going back to 2014 Frimley Park was the first hospital that we rated outstanding, blue for outstanding. We had to find a fourth colour and … after the traffic lights. Even within Frimley Park there was one service that had one cell that required improvement. I’m quite sure that was put right very quickly so it probably doesn’t reflect anything like what they are today. 25 miles away Wexham Park just round the M25 and a very, very different picture, but even within Wexham Park what you see is that children services were good throughout even then. So there was that variation and the intensive care unit was pretty good. The only problem there was they could never discharge anybody. As you probably know Frimley Park took over Wexham Park and this is the transformation that they brought about. The one on the left is the one you’ve just seen for Wexham Park hospital and within just over a year that had been transformed and we can talk about this but leadership, leadership, leadership both managerial leadership, clinical leadership, the clinical leaders from seven of those eight services going into Wexham Park and showing how things could be done differently. Is it just CQC that’s saying that transformation has occurred? Absolutely not. The patient survey shows it, the staff survey shows it, talk to the local MP and she will tell you that the surgeries that she holds it’s just dramatically different.
Just to show that we can look at it for mental health as well here is Northumberland Tyne & Wear which is one of our two outstanding mental health trusts and Norfolk and Suffolk which was the only one that we’ve actually had to put into special measures it’s now out of special measures, but just again to show you the variation. There are far more core services that we look at in mental health.
Just to show you can have improvement in mental health, Calderstones is a Trust it’s now been taken over by Mersey Care but before it was this is a Trust for people with learning disability and I’m absolutely sure that in that period between 2014 and 2015 they responded to things that we had pointed out to them and the care for those people got markedly better in a remarkably short period of time. So it can be done.
I show you that in order now to say what about Western Sussex? This is one of the two main sites St Richards in Chichester and what you can you see here is it’s not a perfect picture and there are some blobs of requires improvement there but there’s a lot that’s outstanding, and if you look down the caring column in the middle it’s all either good or outstanding and the well led being the same. So strength in depth being one of the characteristics that we’re looking for and on the Worthing site a very similar picture but we clearly rated it separately in order that we can then combine those two and we have again rules of aggregation, but overall that’s why we gave it outstanding.
So what do I think are the characteristics of outstanding now that we’ve looked at thirteen Trusts, mental health, acute, specialist trusts that are outstanding? First of all having a passion for patient centred care. There’s no doubt that that passion you can feel it when you go there, you can see it and you see it at all levels within the hospital. It’s not just the Chief Executive, although that would be true of the Chief Executive, but you also see it with the porters and other front line staff. It’s palpable and that’s across a number of these Trusts. They have a strategy. The number of Trusts I go to where we ask them about their vision and their strategy, they have a vision they want to be the best DGH in the country, but they have absolutely no idea how they want to get there and what they’re doing and no way of knowing whether they are getting there. Governance, do they know where the problems are? Do they have the systems in place to alert them to when things are going either well or going less well? There’s one of the outstanding Trusts actually had a problem because they hadn’t been checking on their kitchens and the Health and Safety Executive found real problems in their kitchens. Now of course they put it right very, very quickly and they were mortified about it, but the fact is they hadn’t had the systems in place and so that made them think what are the non-clinical areas that we are missing?
A hugely important point is the engagement of staff and staff culture. The NHS staff survey is probably the most useful single data source that we all have and I’m very glad that more and more Trusts are now doing it on a large scale rather than just a sample and what the staff are telling us about what it’s like as a place to work or as a place that they would recommend for treatment is very important, but then also the characteristics of these really good Trusts is that they do know how to be tough when it’s needed. They don’t have to use it very often and you talk to Chief Executives and Medical Directors, “Have you had to get rid of any consultants?” it’s usually just a very small number that really wouldn’t change but not many at all, and then the final point is it’s about having an approach to quality of improvement and a formal approach. It’s got to be bottom up, you’ve got to allow the teams to do it themselves but you’ve got to support from the top and again, as others have said, that’s all too rare still in the NHS.
So there are things in all of these Trusts that are not perfect, cross boundary working has been pointed out, IT systems and all sorts of other things that can be better, but just coming back to it I think we can say we have some really outstanding Trusts but none of them are perfect.