Behind closed doors: is Kent infection scandal a one-off?

Maidstone and Tunbridge Wells is now the best known trust in the country. And for best known, read most notorious.

A Healthcare Commission report two weeks ago revealed that 90 deaths from April 2004 to September 2006 were ‘definitely or probably’ caused by Clostridium difficile in the trust’s hospitals.

Descriptions and pictures of shockingly dirty wards ensured intense media coverage and scrutiny of the report’s claim that the trust’s board was preoccupied with finance, targets and a private finance initiative project and paid ‘insufficient attention to its responsibilities to protect patients against infection’.

Chief executive Rose Gibb resigned the week before the report’s publication, followed, a week or so later, by chair James Lee.

This much people know. But questions remain. Chiefly: how did a C difficile outbreak of such deadly proportions remain largely unknown until the publication of the report?

Maidstone and Tunbridge Wells trust was formed through an unhappy marriage between separate hospitals and communities 18 miles apart with little in common. While Maidstone Hospital was relatively new, the buildings at Pembury and Tunbridge Wells were old, difficult to keep clean and regarded as not fit for purpose.

In 2001, the first round of patient environment action team reports included the trust in the so-called ‘dirty dozen’ worst hospitals in the country. In 2004 an undercover BBC reporter worked as a cleaner in the Kent and Sussex hospital, exposing poor cleaning practices. A new hospital for the Tunbridge Wells area had been mooted for decades but progress was slow.

In 2003, Rose Gibb, an experienced chief executive, was appointed after the trust had been through a difficult period. Former chair James Lee describes her as ‘feisty and highly intelligent’, although some people found her difficult. She had the task of guiding the trust through the PFI while hitting access and financial targets.

The trust was seeing an explosion in demand while funding rose only slowly: in 2006, Mr Lee says activity went up by 11 per cent while income went up by 1.5 per cent. At one point the trust was ‘close to bankruptcy’. It was struggling to raise productivity by 14 per cent, to cut costs by£40m over three years and to close a significant number of beds. The 18-week target was on the horizon and looked close to impossible.

The Conservatives have seized on the report’s findings as evidence that in the face of government targets, quality of care got squeezed, although Mr Lee insists that he became ‘apoplectic’ over quality issues at trust board meetings. Another board member agrees they were aware of overcrowding, and dignity and privacy issues.

While many nurses at the trust were very good, Mr Lee believes, some were not - and there were problems with how to take action against them.

With the trust operating across three locations there were sometimes differences in approach; the Healthcare Commission report highlights how microbiologists on different sites had different prescribing policies. Clinician buy-in was also low.

C difficile was a relatively new concern for the NHS in the early 2000s but gradually crept up the national agenda. Mr Lee says the board did get information about it but was unaware that the trust’s background level was unusually high. After an outbreak affecting 150 people in late 2005 - which the trust was not aware of - a second outbreak was spotted in 2006.

The trust informed the strategic health authority, which called in the Healthcare Commission to investigate. From early summer this year it was obvious its report would be extremely damaging. A draft was seen by the trust and Mr Lee - who was approaching the end of a four-year term - agreed to stay on for an extra year to deal with it.

Ms Gibb did not accept some of the criticisms in the report and wanted to fight it, although the SHA wanted her removed as chief executive and put in charge of the PFI project. Mr Lee, who asked for a legal opinion on the report and whether it impugned her probity, decided to give her the chance to continue as the question of probity seemed to depend on disputed areas of the draft. ‘I saw Rose as not defending herself but all of us. I may have been naive,’ he says.

Severance payment

In September it became clear the commission’s report would still be extremely critical. Crucially, it would call for a review of the trust’s leadership.

Ms Gibb had to go. The SHA wanted her suspended for six months and then dismissed, but the legal advice to the board was that this was not a good option. It was decided that she should resign with a severance payment. Mr Lee points out that the formal decision in cases like this lies with the trust but insists the SHA was kept informed.

Before the report was issued, he wrote to the SHA chair offering to resign, but was asked to stay to provide continuity. ‘It was for that reason I ballsed it out and went to the press conference and tried to defend the trust,’ he says.

What role can SHAs play in ensuring failings in infection control and patient care don’t happen again? The SHA - originally Kent and Medway and then NHS South East Coast - was only informed of the outbreak in April 2006. But issues of patient care had been raised in public board meetings, by the local patient and public involvement forum and in local newspapers, and the 2004 BBC undercover documentary raised the issue of cleanliness. Nor was it a hands-off organisation, one insider says: ‘All serious decisions were taken by the SHA.’ The SHA points to monthly performance meetings and systems to deal with day-to-day management and leadership issues with trusts.

External pressures

NHS South East Coast was under severe pressure to sort out finances in the county during much of this time. At the end of 2005-06 Maidstone and Tunbridge Wells had an accumulated deficit of£16.7m.

PPI forum chair David Herbert says it had raised issues of patient care, hygiene and hand washing many times. The trust would agree that change was needed but delivering it was difficult and success patchy. Communication between clinicians and managers was part of the problem, he says, but the trust’s focus was very much on financial balance.

Non-executive director Jonathan Paine, who completes his four-year term next month, says: ‘Patient care was supposed to be the top priority but in reality external pressure meant that it had to be balanced against achieving government targets and financial balance.’

While everyone in the NHS subscribes to the ‘patient safety first’ mantra, how is that conveyed at times of financial pressure? C difficile can be contained, but are managers and boards likely to be supported by SHAs to do that if it means cancelling elective operations and delays in accident and emergency?

NHS Confederation chief executive Dr Gill Morgan says there is a need for information from the front line ‘to be freely reported and rapidly transmitted to the board’. Yet that requires clinicians both to be aware of what is going on and to feel able to raise this, even if it is embarrassing or unwelcome by senior managers.

Was Maidstone and Tunbridge Wells really as unrepresentative of the NHS as health secretary Alan Johnson claimed in the wake of the scandal? Even during the outbreak, there were 20 trusts with higher rates of C difficile infection per 1,000 beds - three of those in South East region, claims Mr Lee.

‘I’m not in any way trying to say that we did not make mistakes but to imply Maidstone and Tunbridge Wells was a rogue trust, untypical of anything that is going on in the NHS, is a travesty,’ he says.

Last week the Healthcare Commission revealed that over a quarter of acute trusts were failing to meet infection control standards. The trust’s C difficile rate is now below the national average - figures for April to September are around 60 per cent of the previous year’s rate.

The trust faces an uncertain future. It has insisted for a long time that its PFI project is affordable. But its income may dip as a result of the appalling publicity about cleanliness - many patients in its catchment area have other options. Falling income could make the new hospital look less affordable but failure to build it perpetuates some of the problems the trust faces.

Mr Lee adds that prospective board members for NHS organisations may be frightened off by talk of corporate manslaughter charges. Mr Paine says being a non-executive was a ‘singularly unrewarding experience’, despite having skills in finance and business planning, which he thought the NHS could use.

‘I don’t think I have achieved anything,’ he says. ‘We are there to be the fall guys if things go wrong.’

He says the ‘spin’ on information given to the board made it seem the trust was doing well on clinical measures such as outcomes.

Non-executives are supposed to have oversight of the trust and ask pertinent questions that sometimes challenge the executive management. How can boards ensure they are getting sufficient information - especially when chief executives can exercise control over what goes to the board, as happened in this case?

Roseanne Corben, NHS Alliance spokeswoman for non-executives and the former chair of Maidstone and Weald primary care trust, says there can be problems if chief executives control the flow of information: ‘It is very difficult for new non-executives in particular to ask the right questions.’

Kent county council wants to set up its own ‘healthwatch’ system, ahead of the transition from PPI forums to local improvement networks. It has also suggested three senior county councillors could be appointed to the trust board.

While many might see the council as treading on the NHS’s patch, it highlights the difference between elected councils and the NHS, where non-executives’ role in representing Joe Public is less clear.

As a local solution, it is, arguably, too little, too late. And it does not, in itself, provide reassurance that the same thing could not happen again somewhere else.

To read Nigel Edwards’ article on golden handshakes, click here