When Medway trust became one of the country's reviled 'dirty dozen'no-star establishments, rather than seeing it as a 'failure', the management team drew on widespread support to turn the situation round.Alison Moore reports

There can be few no-star hospitals that would relish a visit from the health secretary - but Medway Maritime Hospital would be happy to open its doors to health secretary Alan Milburn.

Both chief executive Jan Filochowski and chair Janardan Sofat are convinced their hospital is far from 'failing', and would happily show Mr Milburn round to prove their point. All the same, it has been an unpleasant few weeks since the government's performance tables were published.

Medway trust was one of 12 given no stars: Mr Filochowski was given three months - which end on 31 December - to demonstrate improvement.

The days immediately following the ratings announcement were frenzied. The board met the day after and gave its full support to the executive team, putting out an immediate press release.

'We received support from other parts of the NHS, including the region and the local health economy - the primary care group and the community health council, ' recalls Mr Filochowski.

'I got rung up by three local MPs within three or four days, all expressing total support. All four local MPs agreed to attend a staff meeting which 100 staff attended and had a very positive effect on morale. They then went public in the local media to express their support.'

Dealing with the immediate aftermath was very demanding, he says. As well as explaining the star system to staff and listening to their concerns, he had to deal with a flood of interest from the media.

Staff representatives were also interviewed - and were generally very supportive of the managers.

Within a week the headlines were beginning to look more positive, as independent organisations like Medway and Swale CHC voiced their support.

There were heartening moments: an e-mail from one department which was decorated with those elusive gold stars, messages of support from the hospital chaplains and a strongly supportive comment piece in one local paper, which lauded the contribution Mr Filochowski had made personally.

But after a week, the adrenaline stopped running and an eerie silence descended.

'The phone stops ringing and the press moves onto the next story. You are left to deal with a no-star rating and you have to get on with it.

'You realise you are doing things because of the label - That is determining a lot of your work. You have to perform better than anyone else.'

Meetings with the regional office and with NHS deputy chief executive Neil McKay followed.

The trust had got no stars for two main reasons - overspending and breaching the two-week wait for breast cancer care.

When Mr Filochowski came into post in December 1999, the trust had severe management problems. 'By March 2000, I had no executives, the chairman had stood down because of work commitments and there were three non-exec vacancies.

'Within two to three months, it was clear that there was a deep underlying deficit. The region had asked us to achieve a£700,000 surplus, but we found we had an overspend of£350,000 a month -£4m a year.'

By January this year, the trust was balancing its books and it expects to break even for the year - but limiting the financial overspend to£1.5m came too late to affect the performance ratings.

On breast cancer, Mr Filochowski admits: 'We took our eye off the ball and we did not pursue that as much as we might - perhaps because the regional accreditation of the service said how good it was.'

Part of the problem was having a key consultant off work ill for some time. For the past few months, the unit has been seeing 100 per cent of women within the two-week target, and for the past four weeks it has been achieving the 'gold standard' of moving patients from diagnosis to treatment in under four weeks. 'We must now be in the top 5 per cent nationally on something where we have been marked as a no-star trust.'

And, as Mr Filochowski points out, on many other indicators the trust has been performing well: it has not had a 12-hour trolley wait since December 1999, and it has coped well with a very significant increase in daily admissions.

For 10 successive days in January, it accepted the intake from a neighbouring hospital which was under pressure - without cancelling elective operations.

The knowledge that the trust was performing very well on these fronts has been important in keeping up staff morale. Mr Sofat says Continued from page 11 the staff were confused by the star rating: 'We were applauding them for their success and then the star system came out, which was more than a smack on the wrist. It demoralised the staff initially, but it galvanised them to say 'That is not right and we will prove it'.

'I was worried that some of the other indicators where we had done OK, we could slide back down, ' says Mr Filochowski. 'West Kent health authority suggested we had slid back on a couple of them and it took three to four days to establish that we hadn't.'

Systems were put in to ensure that accurate information was available more quickly - including weekly meetings and staff designated to track results. 'We have had to put in tighter monitoring systems, ' he says. 'And we have changed our reporting to the board, so we go through all of these targets individually.

'The no-star rating was a heavy price to pay, but it has energised us more. I know to yesterday what is happening on every target - I would not have known that a month ago.

And if it is not OK, I wouldn't be sitting here (holding an interview) - I would be on the job.'

But part of 'achieving' in the 21st-century NHS is not just hitting the targets you are judged on today - it is anticipating what tomorrow's key objectives are.

In nearly two years at Medway, Mr Filochowski has seen the targets move: from trolley waits through inpatient waits to outpatient waiting times and waiting-list numbers. 'We can't afford to let any balls drop, ' he acknowledges. 'We have to perform better because of it - and do that very publicly.'

Mr Filochowski expects waiting-list targets to feature prominently in next year's performance ratings. The trust has reduced its numbers of 26-week outpatient waiters by 60 per cent since April - and has seen reductions of 20 per cent in its 13-week waiters, at a time when national figures for both have been rising. Last year, it had no 18-month waiters.

But it has been no easy task: Medway has had some of the longest waiting lists in the country. 'We had a huge task this year in getting down to 15 months for inpatients - we have hundreds and hundreds of patients to see, ' he says. 'But at the end of September, we had got rid of all our 17-month waiters. Last week, we got rid of all our 16-month waiters. We now have 40 15month waiters.We may get rid of them all by the end of November.'

There are encouraging signs, too, for those waiting 12 months and over: numbers have declined by 80 per cent between March and November. This success has not come about through chance, insists Mr Filochowski. He has been using innovative ideas and techniques, such as remodelling care pathways and 'lean thinking'.

He says: 'I am convinced that at the end of all this, people will know that we are a very good trust.'

Ironically, much of this success has already been recognised centrally - Mr Filochowski recalls Modernisation Agency director David Fillingham suggesting there was little point in sending in his visits team to Medway when it was obviously performing well.

Medway has also held masterclasses for other trusts in how to manage waiting lists.

'Whenever the region asks who is getting the processes right, the answer is 'Medway', ' says Mr Filochowski, with an understandable hint of pride. 'When I went to the region's star meetings, some of the trusts were saying how impossible the 12-hour trolley wait target was. I said 'I can't remember, It is been 18 months since we had one'. They looked at me as if I was from Mars.'

Anyone for a trip to Mars, Mr Milburn? l