NHS fixer Jan Filochowski believes honesty with staff is the first step to dealing with a trust in crisis. Alison Moore reports

In any list of NHS organisations in difficulty over the past few years, West Hertfordshire Hospitals trust must come towards the top. It has had financial problems combined with bitter opposition from many in the local community to long-running plans for reconfiguration.

But when the trust got a "double weak" rating from the Healthcare Commission for the second time last year, it was time for change at the top.

Jan Filochowski was drafted in as chief executive for an initial six months from November, now extended for another six months. He spent much of his early weeks just talking to people, before giving an assessment of what the problems were and what needed to be done.

"Managerial honesty is absolutely fundamental to my approach. Being honest can be very hard, but without it you won't get anywhere," he says. "It is about managing people's understanding of the problem. That may mean getting them to understand that things may be worse than they thought, but that is an essential prelude to starting to put things right." But, he adds, often staff are well aware of what are the problem areas - and are sometimes surprised things are not worse.

One immediate concern was the elective care centre which had been set up at St Albans City Hospital in September and was a key part of the planned turnaround of the trust. Staff shortages meant a high proportion of operations were being cancelled, often very late, which meant the trust was then obliged to offer another date within 28 days. It lacked the capacity to do this and ended up buying in the operations from the private sector.

Tight financial controls meant permanent staff were not being recruited - and yet managers felt under pressure to run lists and then ended up having to employ agency staff. The financial effects were crippling: an overspend in October alone of£500,000.

Getting the centre running properly has significantly cut cancelled admissions and dramatically improved its finances.

Another problem was infection control: the first six months of the year had around 80 C difficile cases a month. Isolation wards and changes in antibiotic policies have helped to combat this and the level sank to nine cases in March. MRSA is also down.

Financial problems were also pressing: Mr Filochowski had been led to believe turnaround was beginning to produce effects, but found the situation much shakier than he expected as planned savings had not materialised. Tight controls on spending were having a stultifying effect. "I found examples of people taking temporary decisions that were very expensive because they did not feel they could take the permanent decisions that would have been better."

The target of£5m surplus for 2007-08 was not achievable and there was a danger the trust could be£6m-£7m adrift. It had been reactive to financial pressures and was taking ad hoc decisions in response to crisis.

Budgets holders have now been given more discretion in taking decisions. Intensive discussions have been held with the main contractual partners, which has led to a rebalancing of the contracts. The strategic health authority agreed to a reduced target of£2.4m surplus, which the trust expects to have met.

Missed targets

Another concern was the likely Healthcare Commission rating for 2007-08. It looked as if too many targets had been missed by too wide a margin in the first few months of the year to get anything but a "weak" for quality. "We had let a whole load of targets go beyond repair. I had to tell people that, internally and then externally, so we could change expectations," Mr Filochowski says. "I thought it would be impossible for us to get a better rating but I am now confident we won't get a weak on either score."

Papers to the January board meeting explained where the trust was likely to fail on individual targets and also set six key objectives for 2008-09. But concerted effort by staff has improved performance in many areas. For example, the ethnic monitoring target was being missed by a mile but was relatively easy to improve.

Staff morale has also needed a lift after years of criticism in the media and failed targets. Mr Filochowski is upbeat about the future of the trust, insisting it could get foundation trust status within 18 months. He has also supported spending on the physical fabric and environment of the trust's hospitals, which is guided by staff groups.

Mr Filochowski arrived at West Hertfordshire Hospitals just after consultation finished on the final pieces of reconfiguration for the trust: a decision had already been made to concentrate most acute services at Watford, which was fiercely contested in Hemel Hempstead, where many people believe their hospital is losing out.Elective work has now been confirmed as staying in St Albans rather than going to an independent treatment centre.

A challenge for the future is opening the planned acute admissions unit in Watford - a key part of the trust's blueprint for the future which will help it cope with emergency demand. This was scheduled to open in August and staff had been told there would be no annual leave for part of the month.

Mr Filochowski was adamant that the move needed to be closely managed: he has set up monitoring procedures, moved the opening date back and reversed the decision on leave. Staff are encouraged to "out" issues as they spot them rather than insisting everything is okay. More slack has been put in between the building being handed over and services starting.

In the longer term, the trust plans to redevelop its Watford site in a joint venture with Watford Football Club and the borough council. This may not be complete until 2014-15.

Mr Filochowski expects to move on well before that. This is his fifth chief executive role - most recently he has been working on national projects - and it has been "mentally and emotionally draining," he says. "I had almost forgotten how demanding a chief executive's job is - but it is rewarding."