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Bringing the Keogh 14 in from the cold

It is lonely at the bottom. That is the message from Sir Bruce Keogh’s review of the 14 trusts with the poorest mortality figures.

Reading his concise and perceptive report, a picture emerges of organisations cut off from the best practice that flows through the blood stream of the most successful trusts.

‘The sensible conclusion that Sir Bruce reaches is that “these trusts will need considerable and sustained external support” to improve’

The Keogh review trusts are places which “tend not to be well linked to professional networks and other centres of knowledge”, and where “attracting top managers is a long-standing challenge”. They are the trusts at which the “capability of medical directors and/or directors of nursing” is questionable and where “boards too easily accept the assurances they were receiving”, while “not really listening to contradictory evidence.”

Not another Mid Staffs

These trusts “manage” complaints rather than seek patient feedback and employ staff who feel “uncomfortable raising issues with senior management”. They do not know how many nurses work on their wards − sometimes risking the quality of care − and, as a result, deal badly with “complex deteriorating patients”.

This − rather than financial pressures or rising demand − is what marks these trusts out as unusual.

The sensible conclusion that Sir Bruce reaches is that “these trusts will need considerable and sustained external support” to improve. There may yet be changes at the top of these trusts − and they may sometimes be warranted − but it is to be hoped in most cases their leaders are given enough breathing space to make use of that support.

None of these trusts are “another Mid Staffs”. Given the deep seated problems many of them face, these organisations need time to come in from the cold, not to be buried by an avalanche of constant criticism.

Readers' comments (11)

  • Very wise Alistair. I loathe the term hit squad as it implies sharp and short. These organisations (and others still to be identified) together with their local partners will need sustained help and no doubt some controversial service changes as well. Can't be done overnight and can't be done by a beleaguered team

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  • Steve Turner

    Absolutely, engaging and supporting is what's needed.

    Break down the culture of fear and real change will take place. There's so much untapped potential which has been held back by dysfunctional hierarchies, and lack of a long term patient centered plan.

    I see everyday how working to change the culture can bring amazing benefits.

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  • After the newspaper headlines at the weekend about Jarman's supposed13,000 deaths it is surely very significant that Bruce Keogh, in his signed letter at the beginning of the report, says about the mortality calculations:
    "However tempting it may be, it is clinically meaningless and academically reckless to use such statistical measures to quantify actual numbers of avoidable deaths."
    Such statistical shroud waving is the very antithesis of the cooly rational approach needed in dealing with the serious clinical problems that occurred in these hospitals.

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  • Every one who works in the NHS is fully aware that there is good practice even in the hospital that may be deemed as failure and the reverse is also true. There are excellent caring nurses within Dept that harbour poor practice. Some managers are so good at talking that they don't challenge poor practice but cover it up. Until such time as one is able to identify managers with genuine concern for patient care this system will continue.

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  • Alistair is right. Tabloid lynchings are not helpful or humane, but there are some senior teams who have simply failed. There are no excuses, but just because they've failed doesn't mean there's no way out of the cold.

    If there's one lesson we have to learn, it's that nursing is not something to take for granted because it makes such a massive difference to the safety & decency of patient care.

    As Anonymous | 17-Jul-2013 8:29 am points out, impression management & covering up understaffing and poor care has led to this. I know because I worked in just such a Trust and with such incompetent managers. We can all see the results.

    I'd have liked some of the answers and management support to have come from nursing itself, but looking at the NMC and RCN, this seems miserably unlikely.

    The first thing these Trusts need to do is take a hard look at their senior nursing team and make sure it's fit for purpose and ensure that they're staffing all clinical services with Real Nurses, not just HCAs or agency staff, every day and every night your services are available.

    Then set up monthly reporting on a set of robust clinical outcomes and focus on complaints and risk issues. Don't stop till you are 100% sure that each of these issues are dealt with, but check anyway. Get your nurse director working alongside the staff teams and reporting directly & fully to you.

    Nursing isn't like heat and lighting - you can't just pay the bill and take the quality for granted. You need to know it's effective because your job truly depends on it.

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  • I can't be the only one who sees the irony of the armies of ex-Nursing Directors who sit at various risk summits on behalf of NHS England, Regional Teams, Local Area Teams, CCGs, CQC, NTDA, etc. bemoaning the quality of Nursing Leadership at Trust level. Much easier to be one of the armchair critics than do it yourself.

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  • Regarding Mr Scally comment " Jarman's supposed 13,000 deaths". This is exactly the type of cynical defensive rhetoric used by the DOH, SHA and Mid Staffs management at the time to try and undermine Professor Sir Brian Jarmen data when he first made his findings public...Let us not forget it was Sir Brians work on mortlaity rates which shed light on the tradgic events at Mid Staffs...some people simply never learn it seems.

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  • David Moore

    Further to the comment of ANONYMOUS 17-JUL-2013 8:29 AM that the NHS needs managers with a genuine interest in patient care I would assert that the entire organisation needs to undergo a re-connection with the original caring mission of the NHS. The provision of patient care is the ultimate function of the NHS and therefore the ultimate 'business result' that should be measured and towards which every activity should be focussed. The legendary tale of John F Kennedy visiting what was then Cape Canaveral comes to mind: The President approached a man in overalls sweeping a floor in a large hanger and asked what he was doing; 'I'm helping to put man on the moon Mr President' came the reply. Imagine if everyone at every level of the NHS had a belief that they were helping to care for patients...now that would make a difference!

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  • Very well said David. It is a sad reality that most doctors, nurses and other staff genuinely want to do their best of their patients but it is our NHS culture, poor leadership which creates corrosive energy and make them what they become. Some still continue to work hard, many become indifferent, many give up and at the end most staff end up as being mediocre. Most of them they care dearly for patient safety and quality but feel helpless and put up with bad behaviour and poor care. We need strong leadership, good culture, where everyone puts patients at the heart and their safety, their care and their wellbeing matters more than anything else and everyone is signed up to that principles and staff feel happy and provide good quality care. Focus on leadership, culture, create an excellent and positive energy, have robust governance and good performance management for everyone in the organisation including all the leaders and managers. Happy staff – happy patients.

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  • Good report from Bruce Keogh.

    Good editorial too.

    The report states “During several of the reviews, staff came forward to tell the review teams about their concerns in confidence. These staff felt unable to share their anxieties about staffing levels and other issues with their senior managers, which suggested that staff engagement at some of the trusts was not good.”

    This is still absolutely typical of too many Trusts. It's why we still need whistleblowers.

    It is a culture we have to change.

    Some trusts are making good progress on this. Many have hardly started. Staff loyalty has to be to their patients not to their employer when it comes to patient care and safety.

    His focus on staffing is truly welcome as I have suggested in http://tinyurl.com/mjxs59t

    Let's see if Bruce Keogh's report is an outlier or a harbinger of a new honesty and incisiveness in such inspections.

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  • I think it is right that the Keogh review emphasises help and support for these trusts. They have many good staff who are doing good things with the patient at the heart. Some guidance and support with strong leadership and 'breathing space' they will improve. I believe the AHSNs play a pivotal role in addressing the issue of isolation and sharing best practice.

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