There are many factors that play into a trust’s performance. It is a complex web of leadership, finance, staff engagement and strategy, and the wider care system has just as much to do with it as the organisation’s leadership does

Reading more coverage of our poor local hospital trust, you wonder what makes for success? 

We often read how important leadership is. Our local trust has had many changes in leadership.

The troubled trust

Twenty years ago the new “trust” was not considered to be among the best in the area. But a “new” leadership led to it having three stars and being a contender in the first wave of aspirant foundation trusts. But then stars were lost, finances got worse and the foundation status bid stalled. 

In came new leaders and the finances turned around, debts were paid off, excellence was awarded and foundations trust status was attained. 


‘Out go the old leaders and in come the new ones, but then we drift into further uncertainty’

Out went the old leaders and in came new ones and progress was made again.

Two years on and issues with the mortality rates led to a place among the 14 hospital trusts in the Keogh review of organisations with high mortality rates, verging on special measures. 

Worse followed as other issues emerged. Investigations and inquiries questioned the leadership team.

One by one, executives and non-executive directors departed under pressure. This time we did not get new leadership; we got interims and began to drift into further uncertainty. But even with new people, issues continue to come to light and our local newspapers carry the failure stories.

Using what we know

No doubt a new leadership lies in waiting; no doubt a few years later they will become the new villains.

Maybe leadership supplied by the strategic health authority or by Monitor or by the men in grey suits is not enough.

So what do we know? 

We know that the staff are not to blame – the Care Quality Commission says so. We also know that for many years staff relationships at the trust were not good enough. Finally, we know that trusts with high levels of staff satisfaction do well and that effective staff engagement is a pointer to success.

But are staff relationships poor because the trust has had years of struggle or did falling morale cause the problems?

‘Having the right numbers and mix of staff is vital and that has not been addressed’

Having the right numbers and mix of staff is vital and that too has not been addressed despite valiant efforts – maybe it’s a funding thing.

Too many services locally are consultant led rather than consultant delivered and there are not enough nurses – that means not enough real nurses actually present on the ward.

We know that medium sized acute trusts are unlikely to be sustainable. The strategy for our local trust is opaque; does it go for vertical or horizontal amalgamation or approach integration of services some other way? Or does it pretend it has a standalone future through greater efficiency, increasing activity and rising tariffs?

More than just good leadership

Not having a stable management team, having too few staff, poor staff engagement and no clear strategy does not look promising. We need better leadership.

It is blatantly obvious that having a competent, stable leadership and management team is a good thing, and there is evidence that the few trusts that have performed well over a long period – of which there are very few – have stable leadership; think Sir Alex Ferguson at Manchester United. 

But do trusts fail because leadership fails?

‘Whether a trust succeeds or is branded as failing is as much about the wider care system as it is about its leadership’

Probably not, it’s more complicated than that. 

Having enough “funding” must be important too and the quirks of funding formulae and local commissioning make this a lottery not controlled much by the leadership at the trust.

The environment in which acute trusts perform is complex, with many factors such as the quality of commissioning. Primary care is often outside the control of the trust too.

So unless the trust is a major teaching hospital, whether it succeeds or is branded as failing is as much about the wider care system in which it is located as it is about anything that its leaders, managers or a dedicated and well motivated workforce can deal with. 

Richard Bourne is chair of the Socialist Health Association, a membership organisation affiliated to the Labour Party