Friday, 27 June 2014

Morecambe Bay Hospital Trust under Special Measures after 'Inadequate' rating.

Royal Lancaster Infirmary

The University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB) has been placed under 'Special Measures' following an inspection report made public today by the Care Quality Commission (CQC). The report has rated the UHMB Trust 'Inadequate', mainly due to poor staffing levels.

'Special Measures' involve action by three organisations: the CQC, Monitor and the NHS Trust Development Authority. All are independent but funded by the Department of Health, working closely together. (See Special Measures information sheet)

As part of the special measures, NHS regulator Monitor will appoint an Improvement Director to provide support and expertise and also to hold the Trust to account.

Failure to comply with warning
While hospital care at the Westmorland General Hospital in Kendal was rated 'Good' overall, both Furness General Hospital in Barrow and the Royal Lancaster Infirmary (RLI) were rated 'Requires improvement' across a range of  areas, with at least one area of each hospital being found 'Inadequate' or 'Poor'. The inspectors 'concluded that the trust had failed to comply with the earlier warning notice.'

You can read all the reports on the CQC website.

RLI Medical Care 'Inadequate'
A key area of concern at the RLI was Medical Care (including older people’s care) where it was found that all staff are caring, compassionate and very hard-working, and so rated by the patients, but hampered by inadequate staffing levels across the grade range, which resulted in increased risk to patients, inadequate nursing care and significant loss of dignity.

Struggling with budgets
The Trust achieved Foundation status in 2010, having been dogged for several years by the need to make heavy savings to meet budget targets. This was just one more of a series of expensive and complex NHS reorganisations as one government after another had looked at ways of monetising the nation's needs for health care.

Matters came to a head in 2011 when a scandal erupted over revelations about a series of avoidable deaths at the Furness General Hospital maternity units in 2008. With the recent lessons from the Mid-Staffordshire Hospitals Foundation Trust humanitarian disaster fresh in mind, this resulted in a spotlight being brought to bear on a wide range of critical organisational failures across the Trust.

The Trust was temporarily taken over in 2012 by government watchdog Monitor following a series of  CQC inspection warnings and checks. See previous report: 'Watchdog threatens closure of RLI A&E Department'.  Trust Chief Executive Tony Halsall 'resigned' in early 2013 with a golden handshake and the entire Board has since been replaced.

A further scandal erupted when it was revealed in 2013 that the CQC had deliberately suppressed an internal review that highlighted weaknesses in its 2010 inspection of the UHMB Trust and that the Commission had "provided false assurances to the public".

While key areas of concern, such as the A&E, Maternity and Stroke hospital services were effectively targeted for improvement in 2013, the Trust was still struggling with its budget, and in May 2013 circulated a consultation document (see VL report) looking at ways to shave a necessary £30 million from its £250 million annual budget - a reduction of 13%.

At the same time the Health Trust also faced the challenge of adapting to the  fundamental changes to the NHS brought about by Conservative Health Minister Andrew Lansley's new Health & Social Care Act which gave responsibility for commissioning medical services to newly formed, GP-led Clinical Commissioning Groups.  New private contracting arrangements and deep cuts to social care services led to A&E departments coming under additional pressure nationwide while reorganisation and 'fire-fighting' expenses ate into budgets across the NHS.

CQC Warning
In October 2013 a further CQC inspection found significant failings in the care provided at the RLI and issued a further warning.

A follow up inspection in January 2014 found that although steps had been taken to resolve some of the issues, the medical wards were still failing to provide adequate staffing levels.

The inspectors concluded 'that the Trust had failed to comply with the earlier warning notice.' 

"Staffing concerns were also identified in other clinical  areas such as the surgical wards, radiology, dermatology  and paediatrics, where there is a shortage of specialist  staff.  Staffing issues within the hospital have been recorded on  the trust’s risk register for some considerable time;  however, the trust has been unable to address these  concerns effectively."

Praise for the Front-Line staff
The inspectors were careful to note that there was no fault on the part of any individual front-line staff or their mid-level line managers, who all showed a high level of caring; rather that they were challenged in carrying out the work to which they were committed by  inadequate staffing levels which made it impossible to always maintain high quality systems of care. Recruitment remained a 'fundamental concern'.

Blame for the high-level management
The report went on to say that " responses and improvement actions are seen as lacking vigour and pace. The trust’s governance and management systems are  inconsistently applied across services and the quality of performance management information requires improvement. 

"We also found that performance  information and learning from incidents was not  effectively used to drive changes and improvement.  There have been improvements in both the maternity  and accident and emergency services as a result of  targeted and focused work by the trust, and patients are  positive about their experiences of these services."

Trust response
The Trust's Chief Executive Jackie Daniel issued a statement on her blog today (read  full statement) saying:

"Over the last two years we have seen significant improvements in areas such as mortality, staffing levels, A&E, complaints management, maternity, record keeping and appointments, many of which are recognised in these reports. It isn’t all fixed and there is much more to do but I am confident that we have progressed, although at times not at the pace needed.

"There are a number areas highlighted that need urgent attention, particularly in our medicine division. It is clear that some aspects of safety and quality within this division were not meeting acceptable standards. It isn’t good enough; the CQC standards should be seen as the minimum standard of achievement. Our priority must always be the safety of everyone who uses our hospitals; therefore it is alarming to receive such a poor rating in these areas. 

She went on to say "I am confident that together with our partners, we have an emerging strategy through the ‘better care together’ programme to transform health and care services across Morecambe Bay.”

Better Care Together
'Better Care Together' or is a 'consultation' process looking at regionally centralising some hospital services  and replacing them locally with 'care in the community' options.  In 2015/16 about £2bn from the NHS budget will diverted from hospital funding to be put into the Better Care Fund, intended to help the NHS and local councils provide more integrated health and social care, mainly via contracts with private agencies.

Trust plans currently underway were aired at their 'Better Care Together' stakeholder meeting last Saturday in Kendal. They include the downgrading of Westmorland General Hospital - the only Trust hospital still rated as performing adequately - and the outsourcing of hospital pharmacy services to Alliance Boots. One reason why Alliance Boots was able to underbid its rivals was because of its skill at UK tax avoidance.
The Medact charity has recently launched a campaign to get Alliance Boots ('based' in tax-haven Switzerland) to pay its fair share of UK tax on its activities in the UK.

Costs of privatisation
UHMB is not the only Trust caught in the struggle to maintain quality standards in the face of tightening budget restraints. Monitor estimated last week that there is a funding gap of just over £5bn for 2015-16 in the NHS in England's £78bn commissioning budget for all secondary healthcare - which makes up about three quarters of its total budget and includes hospitals and mental health services.

Even after all realistic efficiency savings are made, Monitor says, a deficit of £1.6bn will remain in this section of the budget.  The concerns over the NHS budget in England come after recent research by the Nuffield Trust suggested the NHS in Wales was facing a £2.5bn funding gap over the next decade.

But with about 225 parliamentarians and 145 Lords with recent or present financial connections to companies or individuals involved in healthcare, the increasing government pressure on quality public health resources to skimp services to skim profit for private investors and contractors can only be an obstacle to quality public healthcare.

It will be interesting to see what solutions the newly-appointed 'Improvement Director' will find.

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