Last October Maidstone and Tunbridge Wells trust was the subject of sensational headlines over deadly superbug outbreaks. A year on, under a new chief executive, it is being transformed from ward to board
Walk into Maidstone Hospital today and you cannot miss the banks of gel dispensers immediately inside the entrance - or the number of visitors, patients and staff using them.
It is a very public statement of the priority the trust that runs the hospital now gives to infection control and the reassurance it wants to give the public.
A year ago Maidstone and Tunbridge Wells trust was the subject of one of the Healthcare Commission's most damning reports. It detailed the failings that contributed to two significant outbreaks of the healthcare-acquired infection C difficile and arguably to the deaths of up to 90 people.
The trust was immediately subsumed in a media frenzy. From the health secretary making a direct intervention to halt a payoff to its outgoing chief executive, to the chair resigning amid bitter recriminations over what went wrong, barely a day went by without a freshly damaging story in the press.
For the trust's staff, spread over three hospitals, it was a terrible time.
"You should not underestimate the pressure they were under socially as well as in dealing with patients and visitors," says Glenn Douglas, who was appointed interim chief executive in October last year on secondment from Ashford and St Peter's Hospital trust before deciding to stay on. "Six thousand people work in this organisation and the vast majority of them live in the local community."
A year on Mr Douglas can joke about being surprised that not everyone recognises him in his local supermarket but, at the time, the opprobrium attached to the hospital had an enormous effect on staff morale.
Interim chair George Jenkins says staff were traumatised, with some even denying they worked at the trust.
And Margaret King, a member of the local Unison branch committee and nursery nurse at Maidstone's maternity unit, recalls being harangued by a customer in a shop car park.
When Mr Douglas first visited the trust three days before publication of the report - following a midnight phone call from the strategic health authority suggesting he take up the post - there was still denial about the failings of the organisation, he says.
"My role was about getting the organisation very quickly to recognise the realities of the report but also supporting the staff. I was really quite impressed by the quality of the staff and also their attitude. It gave me something to work with."
Sara Mumford, now director of infection control at the trust but then with the Health Protection Agency, was called in at the height of the C difficile outbreak in 2006.
"It was horrendous. There was disorganisation, a lack of clarity about what was going on, whose responsibility it was and how it was going to be sorted," she says, adding that the situation at the trust made the outbreak "an accident waiting to happen".
Immediate improvements were made in cleaning and in antibiotic prescribing and things started to get better - as did staff morale, although that received a severe knock when the Healthcare Commission report became public last October. But when Ms Mumford came into post in November things were moving forward and she says she was pleasantly surprised at how upbeat people were and at the willingness to make improvements. Director of nursing Flo Panel-Coates - who came into post recently from North Middlesex University Hospital trust - has similar impressions.
But at the time of the report's publication, public confidence in the trust slumped. In the first few days after it came out there was a steady stream of patients cancelling appointments and complaints subsequently rose.
Patient numbers have since recovered and stabilised - and compliments from them are rising - but while public confidence has started to return, it will be a long haul. Mr Jenkins hopes to set up a patient council with perhaps 200 members to feed back experience and ideas to the board. Staff recruitment seems to have been unaffected. The trust has had no problems recruiting medical staff and although finding nurses has been tough, it believes this is a reflection of the national position rather than something unique to the trust.
Mr Douglas is careful to emphasise that the trust is still on a two to three-year journey. What has changed, he says, is the culture.
"I think people feel more empowered. One of the real problems [before] was that people felt disempowered. We are not without our problems still, but people feel more in control of their own destiny.
"The public read the report as being about C difficile. I read it as C difficile being a symptom, a manifestation, of an underlying malaise in the organisation."
But operating an open, honest culture can sometimes slow down other changes. Getting the right senior management team in place (which inevitably meant some departures) has taken a long time.
"I did not go in with a large axe on the first day," says Mr Douglas. A ruthless clear-out of staff could have given the wrong message about the culture he was trying to inculcate. Short-term measures could have helped reach some of the other targets but would not have been sustainable in the longer term.
In many ways the trust still faces enormous challenges. It is struggling to meet some central access targets such as 18 weeks and accident and emergency attendees being seen within four hours. It currently projects a deficit of£3.8m, even after support from the primary care trust. Mr Douglas admits that the South East Coast SHA has cut it some slack but adds that this aid is unlikely to be open-ended.
"Our performance on other main targets definitely dipped as a result of the focus we put on infection control in the early months. Once the scrutiny is off, it is important that we rejoin the real world agenda. But every trust faces the same balancing act. You can't take your eye off what is the primary concern of patient safety and care."
One problem the trust no longer faces is being a poor performer on infection control. It is now in the top half of trusts for infection rates and has achieved a 50 per cent reduction in MRSA over three years. C difficile rates in the first quarter of this year were 73 per cent lower than in 2007.
Ms Mumford says support from the top has been strong. When consultants complained about the "bare below the elbows" policy, the chief executive led the way and is now usually in short sleeves and without a tie. An isolation ward is a permanent fixture of the trust even though that means removing those beds from normal stock and some will lie empty much of the time.
And on the wards, nurses are finding their voices are being heard, says Ms Panel-Coates. Improved communication from board to ward and back up again has helped and is now backed up by meaningful performance data. Senior nurses now spend time each week on the wards. Mr Jenkins says non-executives are much more visible and are passionate about patient care.
But it will be a long time before the Healthcare Commission report fades from memory.
"I have never seen a story which has reignited so many times," says Mr Douglas. Each new twist of the story has been difficult for staff and he is acutely aware other twists are still to come - the anniversary of the report's publication and tribunal hearings over the payoff of former chief executive Rose Gibb among them.
"We live under a microscope and will continue to do so," he says.
But Mr Jenkins adds: "There comes a time when staff have to hold up their heads again. I think that time is coming."
Ms King says pithily: "There's a limit to how much you can beat a donkey."
But was Maidstone and Tunbridge Wells a "rogue trust", as was asserted at the time?
"I have sympathy [with those in charge of the trust at the time] only to the extent that there was a huge agenda. I doubt many trusts faced the size and complexity of the agenda at Maidstone and Tunbridge Wells," says Mr Douglas.
But there were other trusts with higher infection rates and some problems highlighted in the report had marked similarities with C difficile outbreaks at Stoke Mandeville Hospital in Buckinghamshire, suggesting Maidstone and Tunbridge Wells' problems were not unique.
"We were not the worst. I think we got unlucky," says Ms Mumford.
The report began a national emphasis on infection control and prevention and caused a good deal of navel-gazing at other trusts, with many boards examining the lessons for them.
"If it pulls everyone up short to check what they are doing, it's going to cause reflection in terms of your own system," says Institute of Healthcare Management chief executive Sue Hodgetts. The report also highlighted the need to keep reviewing priorities and challenges - C difficile was far from a household term a few years ago yet no board member can be unaware of it now.
One obvious lesson is that infection control - with all its connotations of public safety and public confidence - has to be top of the board agenda. Although the Maidstone board faced multiple challenges, that was not accepted as an excuse. The message to boards is they need to prioritise patient safety and infection control, as well as coping with all the other challenges of trust life. Given the pressure on the NHS to reduce overspends, this may feel like a change of priorities but is considered in line with the thrust of the Darzi review.
"The key issues in the NHS are around quality," says NHS Confederation deputy policy director Jo Webber, who argues there has been a refocusing over the last year, with patient care and safety now more strongly reflected in assessment processes.
But Ms Mumford still knows of colleagues in other trusts who have to battle to get isolation facilities. The picture is mixed, says the infection control director.
"It does come back to whether the whole ethos of your trust is about caring about infection control. People ignore it at their peril."
However, Royal College of Nursing nurse adviser for infection prevention and control Rose Gallagher believes the message has hit home.
"The investigations into Stoke Mandeville [into two outbreaks of C difficile] and Maidstone and Tunbridge Wells both contain a very powerful message in relation to the importance of governance and risk management. There has been a very real improvement across the NHS in terms of organisations looking at these and making sure they are fit for purpose."
Ms Gallagher says infection control teams are seeing an increase in discussion about the issue, as well as improved reporting on infection control and its inclusion on board agendas. The need for additional resources to tackle infections is also being discussed.
Ms Hodgetts agrees the Maidstone and Tunbridge Wells case emphasised the importance of robust governance for the NHS. According to the Healthcare Commission report, the trust board was not fully aware of what was happening on its wards, nor did this seem to have been conveyed to them at board meetings.
"These are really important issues which have to be on the board agenda all the time and there has to be strategic leadership on them," says Ms Webber.
But what does the experience say about the relationship between the Department of Health and the frontline NHS? As shocking as the report was, the speed and directness of the health secretary's subsequent intervention made it seem that any notion of local autonomy had been dropped in the light of moves to prevent a payoff to the trust's outgoing chief executive.
Guidance subsequently reissued by the DH makes it much harder for future severance payoffs to be decided locally. In some cases, agreements have to be cleared as far as the Treasury. Such moves will make agreeing terms for departure more difficult, possibly even in cases when a speedy exit is to everyone's benefit.
Is this sort of central intervention justified? Ms Hodgetts believes that in a crisis decisions do come from the top. But she contends that there are mixed messages about the extent - and reversibility - of autonomy.
Another outcome of the report was a harsh message for anyone planning to become a non-executive director - namely, that they can expect no support when things go belly up. Former Maidstone and Tunbridge Wells chair James Lee described himself as "being hung out to dry" when he was forced out despite originally being asked to stay on for an extra year.
Other non-executives at the trust came under pressure - to resign or be forced out. One was told that if forced out, they would never get another government appointment. But despite all that, the trust had no shortage of applicants for the newly vacant non-executive posts and was able to recruit candidates of a high calibre.
Even at times of crisis, it seems people still care about what happens to their local hospitals and want to get involved.
2000 Two trusts, 17 miles apart, merge to form the Maidstone and Tunbridge Wells trust.
2001 Pembury Hospital is named as one of the worst hospitals in Britain for cleanliness after the first Patient Environment Action Team inspections.
June 2004 Cleanliness at Kent and Sussex Hospital is criticised after an undercover BBC reporter films there.
April 2004 - September 2006 Two C difficile outbreaks at the trust are the subjects of a Healthcare Commission report. Concerns about hygiene and care are reported in the local press.
September 2006 Healthcare Commission invited to investigate by the SHA and trust.
May 2007 A draft Healthcare Commission report circulates.
5 October 2007 Trust chief executive Rose Gibb leaves "by mutual consent".
11 October 2007 The damning Healthcare Commission report is published. Kent police and the Health and Safety Executive examine it. Health secretary Alan Johnson tells the trust Rose Gibb's severance pay should be withheld.
15 October 2007 Trust chair James Lee resigns, to be followed by the other non-executive directors.
1 November 2007 Mr Johnson says the trust may not have followed due process in agreeing the payoff to Rose Gibb.
24 January 2008 Trust announces Rose Gibb will get six months severance pay only.
7 April 2008 Rose Gibb lodges an attempt to get a full payoff.
30 July 2008 Kent Police and Health and Safety Executive state they will not launch a criminal investigation, so no charges will be brought over deaths attributed to the C difficile outbreaks.