A YEAR IN BRISTOL

Published: 28/07/2005, Volume II5, No. 5966 Page 26 27 28 29

Last year HSJ asked if United Bristol Healthcare trust would sink or swim on the high seas of rapid organisational change. Concluding our four-part series on the trust's progress, Rebecca Coombes looks at how a radical restructure has turned around the trust's fortunes

When HSJ first wrote about United Bristol Healthcare trust last autumn, it was forecasting a gaping£3.5m deficit at year-end (pages 28-30, 28 October). Today, chief operating officer Dr Graham Rich has a hint of a smile as he reports the trust has pulled off zero balance. 'We got there, which is fantastic.' Ever the pragmatist, finance director Paul Mapson is quick to caution against any sudden release of breath. 'We have gone from£15m unadjusted overspend to break-even in two years, which is pretty good. But the ability to find permanent savings year in, year out is very difficult.' This includes, for starters, a£16m savings target for this year. But as Bristol slowly hauls itself off the financial ropes, it now faces a whole new set of challenges: cancer targets that the medical director thought unachievable just nine months ago have to be hit by Christmas; a radical trust restructure has given the medics a controversial amount of power, and a whole raft of capital projects vital to UBHT making it in the new market economy are looking distinctly unaffordable. The trust's hard-won two-star status also looks threatened by some serious waiting-list breaches.

Chief executive Ron Kerr, whose former jobs include heading the now-defunct National Care Standards Commission and a director of operations at the Department of Health, looks unbowed. He went to Bristol with his eyes open.

His philosophy is: 'If you do not control the money, it controls you.' That, it seems, is working. 'I came in knowing there were a lot of difficult things to be addressed.

But I didn't suddenly pick up stones and find very serious clinical issues. That just is not an issue, ' he says.

Medical director Dr Jonathan Sheffield - who admitted the last time HSJ spoke to him to finding Bristol's problems 'nerve-wracking' (pages 28-31, 28 April) - is also looking chipper.

He will need all the energy at his disposal to tackle the December 2005 cancer targets - a maximum one-month patient wait from diagnosis to treatment for all cancers, and a maximum twomonth wait from urgent GP referral to treatment for all cancers.

'It is a target I believe in, although I do get sick of going to national meetings and being told how important they are. Sometimes you just want to get on and do it, ' says Dr Sheffield.

'We have had to do a lot of work on it because our data was appalling. Part of the problem is that information systems are not there, so it requires a lot of searching of notes. I am impressed by how the organisation responded to the challenge.' The DoH expects a trust the size of UBHT to be accruing about 400 cancer patients per quarter - at 75 a month, the trust appeared to be receiving nowhere near that. However, this is not because they were not accruing patients, but because they were not adequately recording them.

Achieving financial balance has given everyone a spring in their step. 'It feels like we are in a completely different position, ' says Dr Sheffield.

'For my first eight months we were hammering it home to people - now we have the ability to make much more change.' What is important to Dr Rich is restoring Bristol's reputation as 'appropriate guardians of the public purse'. The wider health economy looks in slightly better shape. North Bristol trust, which had the largest UK deficit on record at£44m in 2003-04, broke even last financial year with NHS support. The local primary care trust broke even, too. The benefits promised by payment by results might even kick in this year, says Dr Rich. 'With payment by results, if we can put more activity through the same infrastructure, we will gain through efficiencies and be paid for what we do.

It is clearly not a blank cheque, but if we are sensible we can invest a little to unblock bottlenecks and make the whole process go more smoothly.' Some cash has already been swiftly put to work. The trust has invested in meeting the accident and emergency target of seeing 98 per cent of patients within four hours. After a disastrous winter, the trust suddenly plummeted into the worst 5 per cent in the country for A&E waiting times. The causes for this were upstream of the A&E department. Patients who needed to be admitted were forced to wait in A&E. Roughly half of those waiting more than four hours in A&E were waiting for a bed. It meant that any chance of achieving the 98 per cent target slipped away in the last five weeks of the financial year.

One of the serious problems was the undercapacity in trauma theatres. Dr Sheffield explains: 'I had several embarrassing complaints to deal with where patients had clearly waited more than 48 hours. Ideally you want fractures of neck and femur seen in 24 hours. Some were waiting four or five days for a theatre slot because theatres were under such pressure.' The trust has now introduced three orthopaedic trauma lists in the evening. 'It is not an ideal time to have them, ' admits Dr Sheffield, 'but we were averaging 12-15 orthopaedic outliers from our orthopaedic ward. They have just gone, so that has released those beds for other patients and we have dramatically brought down fracture neck and femur waiting times. It is a win-win.' The trust has also added extra lists for coronary artery disease. Dr Sheffield says: 'We have been managing theatres very tightly to keep them to budget and now, just by releasing some extra money to get staff in, it has had a dramatic knockon effect on pressures on the wards.' The redesignation of Southmead as a minor injuries unit in June will see A&E traffic increase by some 10 per cent at UBHT, which equals roughly 6,000 extra patients a year. But the trust had taken precautionary action and opened a 22bed medical ward. It has also invested in better junior doctor support for consultants and reworked the nursing rota to match the time of day when most patients come in. On A&E waiting times, UBHT is now 44th out of 155 in the country.

Director of nursing Lindsey Scott also had good reason to feel pleased about the zero balance. 'It has been nursing that has achieved the most in terms of financial recovery in this trust. When I came here in 1998 we had high agency usage. It was 65 per cent agency use and 35 per cent bank. The overspend was around£13£14m. It is been a very hard, complex journey.

There are some very aggressive agencies here, but now we have 95 per cent bank and 5 per cent agency.' Finance director Mr Mapson is also proud. 'We do not have grandiose schemes here, but it is all about screwing down the costs. Look at our agency spend, down from£13m in 2001 to£1.7m this year. That really improves your position.' Chief executive Mr Kerr says his first job when joining Bristol was sorting out the finances; the second was making the organisation 'fit for purpose in managerial terms'. The move in July from 13 directorates to five clinical divisions will enable the organisation to pack a punch, he hopes, though Mr Mapson says he hopes the changeover does not eat up too much cash.

The divisional heads are all clinicians, and noticeably all medics. Seven out of 11 members of the trust executive group are now medics. Dr Sheffield, who is enthusiastic about the move, says it makes for a much richer debate.

'It has helped with the cancer agenda. One of the key issues for the 31 and 62-week waits is the access to the high-dependency unit and intensive treatment unit. We can work closely with heads of division for a solution.' Director of nursing Ms Scott is not so sure.

'One of the big issues for me is being around the medical dominance in the trust. It feels very male here and that has been a struggle. [Dr Sheffield's] arrival has made a difference as he is so pragmatic and he often jumps in and says: 'is not that a medically dominated model?' But I am a bit negative about this new trust executive group. It does worry me that all the five new heads of division are medics and I have to constantly fight.' But Ms Scott is delighted with the move to five divisions: 'It is like a breath of fresh air for people to say we are going to change it. It feels like a different job to me. It is a shift away from that very operational, financially driven thing with nursing into strategic issues such as cleanliness.' Ms Scott says the trust's recent history has taken the focus off the basics. She talks about the Kennedy inquiry into paediatric cardiology as if it were a massive black hole sucking everyone in.

'That is where we lost focus. You have got to get people to survive heart surgery, but It is also important that they are in a clean environment with nice food to eat. There was a focus on pure clinical outcomes before, losing sight of the patient as a whole.' If anything, she says the trust is now so 'riskadverse' that specialties other than children's can feel left out. 'If you go out and talk to staff, especially elderly care, in an old building, they would say the trust puts its money into children's services and its all-singing, all-dancing environment, ' she says.

Mary Douglas-Jones, chair of the public-patient involvement forum, says that after 'getting its fingers burnt' over consent and patient involvement in the heart inquiry, the forum is now one of the best in the country. 'We have had positive experiences here, ' she says. 'There have been difficulties with forums around the country in getting access to managers. But one member of the trust board has come to all of our meetings over the past six months, so we get instant access to answers. It is not a case of someone going off for months to dig out information.' For Ms Scott a huge concern has been to develop clinical governance and quality issues.

The trust has an impressive building plan, including a new cardiac centre. But Mr Mapson admits it is not going to be plain sailing. 'A real challenge for us is to make the capital projects affordable. The current model is that you have to make sure it is affordable within the tariff. And in the main, the extra income from tariff will not pay for a new build.' He cites affordability problems with the new cardiac centre, and the plans to centralise the city's paediatric services. So perhaps sensibly, Ms Scott is focusing on how to make the best out of the situation. 'We have had significant problems with cleanliness, especially at BRI. We brought cleaning back in-house 18 months ago, but there is a huge issue recruiting a workforce in a city where you are working opposite the retail industry.' She is launching an unofficial campaign loosely based on Barts and the London trust's 'smarten up' campaign, which covers customer care, professionalism of staff, how staff present themselves and decorations.

But just when things are looking up, a nasty surprise comes around the corner. A look-back exercise ordered by the Healthcare Commission has revealed that seven patients were not added to the waiting list because of administrative errors or other oversights. Some patients should have been put on the waiting list for treatment as far back as 2003. As each month counts as an individual breach, the trust is facing a massive number of breaches, even if it is a reflection of past rather then current performance.

Even if UBHT loses a star, the talk here is still tough. Dr Sheffield says: 'I suppose I came from a much more market-oriented economy in Dorset and Somerset, where the trust was moving towards foundation status, so I appreciate the need to have core business principles.

'If you know what you do well and how much of what you do well you can do without taxing your resources, it will give you a very good clinical strategy to manage payment by results. If you go into it in the way we have done until recently - whatever came through the door was dealt with through cobbled-together solutions - you will not survive.' Reference costs have come down to close to the national average, which Dr Rich says is 'fantastic for a tertiary hospital'. It is clear there will be winners and losers. Services are already rationalising. For example, there is one single vascular rota for the city.

Mr Kerr sees his job as getting the trust into shape to emerge triumphant in the years ahead.

That might mean less successful specialties going by the wayside. 'Payment by results, increased patient choice and plurality in terms of independent sector involvement means there are no guarantees for us. I like to think that in two years' time we will have evolved into an organisation that knows what it is good at and is prepared to emphasise that. If there are services we are not so good at, we should acknowledge that some other provider should be delivering them.' His goal is for the trust to have some clout in the city - and beyond. 'Bristol has a lot going for it and will one day be seen as one of the leading medical or healthcare cities in the country.

We are in the centre of the city amid huge redevelopment, we are investing in our own site and want to see UBHT be a real player in the city.

I would like to see [the development of] a clinical research centre with Bristol University, for example.' Mr Rich enjoys getting an outsider's perspective on Bristol. 'I was interviewing a potential candidate for a job the other day who said she had previously worked here. She said: 'This place feels different'.' Dr Sheffield, who has been in the job only nine months, remains impressed with the ability of staff to keep the show on the road. 'Big teaching hospitals do have a reputation for not being friendly and not working in a collegiate manner, but I do not get that here. We have some horrible buildings, but when you see people struggling in this environment to deliver a 21st century service and the fact they achieve that most of the time, It is a real tribute to staff.'

GRAHAM RICH

SOUTHERN DISCOMFORT

'Someone the other day called me blunt and I see that as part of my value in terms of pointing out where things need to improve.

'Having worked in the North, that is a standard way of operating for most people.

'There is a different culture in the South where people are more cautious and more careful about what they say and more concerned about how the message is being received.

'Being here hasn't changed me.'

DR JONATHAN SHEFFIELD

CANCER TARGETS

Success in achieving cancer targets is riding on a number reforms at UBHT, not least the recruitment of six newly trained radiographers. The recruits are going to be expected to run extended day shifts twice a week to cope with increased throughput.

'It is things like this that make the difference between success and failure, ' says medical director Dr Jonathan Sheffield (pictured right).

'We have reorganised the way we are managing cancer. It sounds crazy, but because there is an oncology centre everyone thought that was cancer. An awful lot of cancer work goes on in the main BRI, including surgery, but we haven't had that focus across the whole system.' Key to the reforms has been creating a care pathway lead for cancer across the trust. 'The aim is to make you think about cancer being across the whole of the organisation. Then systematically working through what our blockages are for the 31 and 62-day targets.' The trust is also compressing some pre-surgical assessments into one week. Dr Sheffield explains: 'Patients come on Monday to outpatients and have all the work done in that week; a decision to treat is made on Friday. It compresses what had been taking three to six weeks into one. We have to be in a position to take that decision to treat to hit the 31-day target.

'People in the NHS want to be told It is all right to make radical changes. The best thing about the cancer targets are that they have been an agent of change.'

A WAITING GAME

Trust waiting-list co-ordinator Josie Wells, who has special responsibility for surgery, has been at the sharp end of the trust's scramble to reach targets. A staff member for 10 years, she looks back fondly to the day several years ago when she was told she could use the private sector to clear lists.

'There was me working in my little waiting-list office and suddenly I was being told I could book all these hernias at the Nuffield and with BUPA. I never imagined I would have the theatre capacity to work off-site. It worked very well, but consultants felt it was limiting training because routine operations are what they need to learn bigger operations.' Although the money for private sector work has dried up, Ms Wells is pleased to see the trust adopt some smarter thinking on waiting lists.

A new booking system records theatre time and length of stay expected for each patient. For example, a simple mastectomy is expected to take 95 minutes while a bilateral breast reduction will require 220 minutes.

Ms Wells explains: 'It helps us plan our bed capacity and we know whether we are using the time allocated to each session. It saves cancelling patients at the last minute because a session is overbooked. We still have a lot of cancellations because of bed capacity, but we have acknowledged that if we are going to address these problems we have to plan. It sounds simple, but I've been here 10 years and it has never happened before.'

Key points

United Bristol Healthcare trust has pulled back from a predicted£3.5m def icit to achieve zero balance.

It faces a raft of new challenges, ranging from tough cancer targets to censure over waiting-list breaches.

The trust has cut the use of nursing agencies drastically, with 95 per cent of nurses now bank staff.

Non-clinical issues such as litter, food and the appearance of buildings are also being tackled.