Six of the nine foundation trusts reviewed by Sir Bruce Keogh due to high mortality rates are in “special measures”. The use of such measures as a stick to beat a public sector organisation with is well know to me − I was part of a senior management team recruited to turn round a large social service department that had been placed in special measures. The previous team having been held responsible for the failing services.
‘Hospitals don’t lend themselves to over simplified one-word verdicts such as “excellent” and “poor”’
Politicians like league tables and if you have a top five you must also have a bottom five. Special measures implies more than just being bottom of the table − it says failing services and, in the case of health and social care, it says unsafe services.
Yet hospitals, like social service departments, are complex organisations that don’t lend themselves to to over simplified one-word verdicts such as “excellent” and “poor”. The same organisation can have some services that are excellent and some that are poor and a lot that are “satisfactory”.
And so it was in the organisation me and my colleagues tasked to turn round.
No easy way out
In our case the key statistic that condemned us to special measures was the high number of elderly people going into residential and nursing home care. The analysis was that the organisation had failed to modernise it’s services due to a commitment to keep them in house despite being more expensive than the private sector.
‘Staff quickly came to realise hitting targets was not necessarily the same as providing high quality care’
The criticism was that the organisation could have helped a lot more people live in their own homes if they had made greater use of private sector home care and forced in-house services to compete on price. This failure to get over the resistance to change was seen as a failure of leadership.
What I learned from the experience of being in special measures was that what gets you in doesn’t get you out.
Supporting a lot more people in their own home, admitting significantly fewer people to residential and nursing home care, making greater use of the private sector and requiring the in-house services to compete on price was not enough to get us out of special measures. Now we were under the microscope, we had to demonstrate that all are services were “satisfactory” or “good” and that the potential for improvement was “excellent”.
This was difficult to do because the government kept introducing new targets to go with new policies and made budget cuts despite increased demand due to a growth in the numbers of older people. The senior managers became obsessed with performance statistics as the only way to evidence our progress.
Staff quickly came to realise hitting targets was not necessarily the same as providing high quality care. More people could be supported at home by using private home care agencies who paid minimum wages, poorly supervised and inadequately trained staff. More visits could be made if each visit was shorter; the average visit went from one hour to 15 minuets. Finally, when the budget could be stretched no further, sever rationing was introduced.
Getting out of special measures started us on a long road of reducing the quality of services.