Shipshape - Bristol fashion

United Bristol Healthcare trust is on the high seas of rapid organisational change, but will it sink or swim? In a series of features over the next year, Nick Edwards will be sitting alongside managers from different parts of the trust, seeing how organisational change affects - and is affected by - the people who are part of it

I was born there, so I can say it: Bristol is not much of a city. Its football team is one of the few English clubs never to have won anything. The city centre is ugly and what regeneration there is pales besides peers such as Liverpool and Manchester. Its most famous musicians are the Wurzels.

And then there is the health service. North Bristol trust unveiled a record deficit of£44m last year and faces a tough consultation on consolidating its acute services. At least it was awarded a star this year - the ambulance trust got none.

But United Bristol Healthcare trust has perhaps had the roughest time, with the prolonged trauma of the Kennedy inquiry into paediatric cardiology at the Royal Infirmary, and criticism of the children's hospital, exacerbated by scathing inspections, crumbling infrastructure and a distinct lack of cash.

Until recently the job for a change manager at UBHT would have seemed pretty daunting. But is the image - and performance - changing? This year the trust went from zero stars to two. Ron Kerr joined as chief executive in May, the trust having been without anyone in the top post permanently for almost two years.

The trust, centred on Bristol Royal Infirmary in the city centre, is spread over several closely packed sites, a number of them quite run down. In December, plans will be ready for moving paediatric services from North Bristol trust to the children's hospital, beginning in 2005-06. There are also a host of capital plans.A£53m cardiothoracic centre is due to open in 2008, followed by the opening of a community hospital in south Bristol to replace Bristol General Hospital. The trust's aptly named 'Old Building' is due to close around the end of the decade with the expansion of the main BRI.

Of course there is a downside to getting two stars - You have got to keep them. Speaking in his tiny office a few days after taking up post last month, chief operating officer Dr Graham Rich is sanguine. 'It would be fantastic to achieve three, but I am not sure that is possible. I would be pleased if we hold on to two.'He underplays the apparent dramatic jump - the difference between success and failure on indicators can be small.

He is relaxed enough to admit that ratings success is not necessarily a positive: 'When I read UBHT had got two stars, a small part of me groaned because I thought it might make the argument for change harder. There is a real challenge to prevent slippage.'

But staff savour the morale boost that getting stars brings. Clinical director of children's services Dr Jackie Cornish says: 'It would have been very demoralising for everyone to have not been seen to have made progress.

The change, coupled with the appointment of some crucial senior posts, has been electric.'

Director of pharmacy Steve Brown agrees: 'There has been unrecognised good work for a while and It is good to have something to concrete to show change is starting.'

Dr Rich says: 'It has given people that much more confidence. That might make change easier in some respects because we can remind people, 'You have got this far; There is no reason why you can't do more'.'

One response might be, 'We have got no money, Graham'.

Finance is a key issue, with Avon, Gloucestershire and Wiltshire strategic health authority still recovering from a record deficit. The pressure on UBHT to break even is huge - and clearly felt deep into the directorates. The target of achieving a recurring balance by end of 2005-06 would require recurring savings of£23.5m.At month five, the trust was£4m overspent and projecting a£3.5m deficit without action.Dr Rich knows the directorates are already running very cash-tight. 'Some people say we can do it, lots of people say we can't.' If the trust doesn't break even, it will be, in effect, fined.

Some specialties are way over budget - does Dr Rich share cost savings equally or focus on them? Can he take out bed capacity without jeopardising the four-hour accident and emergency target? And would it even save money? Does he use the 'blunt instrument' of a trust-wide recruitment freeze? 'Finance comes before stars for me, because if you do not look after the finances you will not be in business for very long.You dig a bigger and bigger hole.'

Dr Cornish says the financial squeeze is 'very, very hard' but she believes success this year will get money off the agenda at last. 'We have all got our five-year plans for all 25 services.We are all ready to go, but until we break even...' Dr Rich's background in primary care gives him a clear perspective on payment by results and the risks it poses for a trust like UBHT.He reckons they are 'more or less' on tariff after some work last year. 'But do we do more activity, expecting to get paid at tariff and then find the PCTs have blown their budgets?'

A pressing organisational issue for Dr Rich is the directorate structure: 'There are 13 clinical directors and I am not sure that It is clear to them who their line managers are and where problems are resolved. If necessary, we will consider a change in structure.'A consultation paper has already been floated. 'What we do not want to do is spend a load of money on an intermediate tier of management that complicates communications and just creates independent fiefdoms.'

Dr Rich is also wary of timing: 'Is the end of the financial year the best time to implement? It can throw uncertainty into the mix just when you do not want it - people start polishing their CVs and worrying about process rather than delivering on targets.'

Medical director Dr Jonathan Sheffield, who like Dr Rich joined the trust last month, says he is 'quite keen' on a division structure with 'four or five senior medical managers who can not only lead on their divisional issues but actually be leads on cross-cutting themes on my behalf '.

It will inevitably be a sensitive issue for managers.

Emergency services associate director Chris Davies says: 'It could have a massive change if we go to a structure based on a small number of divisions. That said, Graham Rich's appointment to a role that gives him this cross-directorate perspective seems very positive. That is sometimes been a struggle in the past.'

Other managers agree that decision-making has often been glacial.Dr Sheffield is diplomatic: 'I was struck by the number of committees. That has been the culture in Bristol for a while - they used to like committees in Avon HA.'He believes change opportunities have been missed in the region 'because no-one is quite sure which committee or which group should make that decision'.

'I think that has been made worse by the introduction of PCTs and their need to develop a maturity about how they commission. An organisation this size must deal with 20 or 30 PCTs and they're all wanting to make their own individual commissioning decisions and they're often not big enough to make that search for tertiary services'.

Apart from nabbing the people who keep having a crafty fag outside his office window, Dr Sheffield's main priority is communication. 'I am very keen to get out there and walk the job. I saw the director of anaesthesia today and said I would much rather walk his patch and have a conversation than sit in my little office. There are still vast areas of this hospital I do not know exist.'

It is perhaps indicative of the 'trench mentality' of the past that 'There is no-one here been prepared to put their head above the parapet and become medical director'.

'Most teaching hospitals can usually find a candidate.

But my job is to make sure when people do raise their heads, they do not get them blown off.'

Unlike Yeovil, where Dr Sheffield worked previously, UBHT is too big for communication to be done on the hoof, down the corridor and around the coffee machine.

He wants to develop the role of the staff committees.

'A medical director's normal route is through the clinical directorate, but that can be a block on communication. Sometimes consultants as a body do worry about more than just their car parking, ' he says.

He says that attendance at committees is not very good, but hopes that developing their role will make them more popular. One of the by-products of the consultant contract, he says, has been to acclimatise doctors to regular meetings.

Not that the contract has not brought its own problems - the tertiary element is complex. And too many consultants are still insisting on doing more planned activities than are funded. 'What people need to see from me is clarity.We are budgeted for 12 planned activities, so if someone is saying 'I can't do my job in less that 14', my argument is a) I do not believe That is true and b) you're putting yourself and the organisation at risk. Some of the models I've seen have been very much based on old consultant service.'

Something Dr Sheffield is planning to import from Yeovil is the clinical performance monitoring system provided by medical information company Dr Foster.

'When I was cancer lead for the area, some of Bristol's data did look a bit ropey. I think they have invested in coding since, but I am sure a lot of work needs to be done.'

The trust's standardised mortality ratio is 'bang on 100', but Dr Sheffield hopes to bring it down to 80.

Other clinical priorities include diagnostics in an effort to get overall length of stay down.

Both men want to create a more corporate culture.

Move too fast, move too slow - it is an easy thing to get wrong.Dr Sheffield says: 'UBHT has to hit the targets - It is no good sitting in the eye hospital and saying, 'We have hit all out targets and the BRI hasn't; never mind'.'He can understand the separation to some extent because of their relative size.As Dr Cornish points out, the planned investment will mean that the children's hospital will soon be as big as a specialist one like Alder Hey.

Dr Sheffield knows communication has not always been great in the past and consciously avoided getting too close before he joined on 1 September. He spent the first 10 days meeting clinical directors, 'plunging into some of the day-to-day issues' and finding 'the lack of suspicion amazing.'Dr Rich has a similar thirst for getting out into the organisation, and specifically not restricting himself to the filtering that inevitably takes place if you only speak to clinical directors and general managers.

UBHT got some unwelcome press coverage over the summer about its dirty windows and Dr Rich knows that general cleanliness is a big issue for staff and patients.

Everyone he talks to, 'from taxi drivers to the catering supervisor', brings the subject up spontaneously.

'One of the first things I did was clean my own window because I understood it hadn't been done since 1991 - when it was built.'He is pondering a clean-up campaign.

'I do not know what the money consequences are but for me It is a major reputation risk. It is one of the fastest and cheapest things the hospital could do to improve its image. Thousands of people drive past every day.We have got offices that just do not look fit to work in.'

Both men know improvement has been promised before and often not been delivered on. Dr Sheffield says: 'I remember seeing plans for the BRI development five years ago. There is also been two years of uncertainty about who would be the permanent chief executive. It happens everywhere - an organisation can easily slip into the wilderness as people stop making decisions while they wait for a leader to emerge.'

Generally, the managers HSJ spoke to (recommended by the top team but free to say what they wanted) were positive.Mr Davies says Mr Kerr is more 'prescriptive' than his predecessor, but welcomes his ambition for the trust - 'he's made it clear that two stars are not good enough.'

So far there seems genuine faith that progress can be made. But the next 12 months will be crucial. Can they get the financial balance without alienating clinicians?

Can they restructure without losing the managers? And can they put in place capital plans that will actually deliver change?

Who's who at United Bristol: some of the key players

Chief operating officer Dr Graham Rich joined last month.Most recently he was chief executive of West Hull primary care trust.Trained as a GP, a varied career has included stints at the Department of Health, working for the Clinton administration's health team in the US, Boston Consulting group and Newcastle and North Tyneside health authority.The COO role focuses on the in-year activities rather than long-term planning and capital projects.

Medical director Dr Jonathan Sheffield joined Bristol last month from the MD post at high-performing (but small) East Somerset trust.Before that he was regional cancer lead for four years.His original plan was to be give up all clinical work, but chief executive Ron Kerr persuaded him to do one day a week in pathology.

Chris Davies is associate director of emergency services.He joined the trust two years ago from industry.The A&E department's four-hour wait performance has improved from 50 per cent a year ago to a consistent 95 per cent now.His main concern is North Bristol trust's forthcoming closure of Southmead Hospital's A&E department - UBHT is already set to see a 9 per cent increase in A&E attendance in 2004.His wishlist: 'Well, a new hospital really.Some of the fabric here is very poor and the layouts are a significant factor in some of the day to day problems we face.'

Clinical director of children's services Dr Jackie Cornish describes herself as the trust's 'oldest living inhabitant'- by length of service, at least. In her current post for two years, she has seen the children's hospital budget increase from£10m to£44m in the past four years and is thankful that 'new managers see clinical staff as integral to success'.

Director of pharmacy Steve Brown has been with the hospital for 20 years and is also the SHA's lead pharmaceutical adviser.A big priority is the introduction of automation as well as developing new roles for technicians to take on more of pharmacists'responsibilities.

Key points

The image of United Bristol Healthcare trust is changing; its rating has risen from zero stars to two.

The new management team is struggling with tight finances, but the trust must break even.

UBHT managers are aiming to develop a more corporate culture.