Healthy future for Princess Royal hospital

10:22am Wednesday 26th March 2008

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A HEALTHY future for the Princess Royal University Hospital (PRU) is assured says the man in charge of Bromley's hospitals.

News Shopper spoke exclusively to Bromley Hospitals' NHS Trust chief executive Ian Wilson after stories showed the hospital in Farnborough, to be struggling in various areas:

‘There’s plenty of scope for doing things better and faster.’

IAN WILSON ON THE HOSPITAL

• It was served with an improvement notice by the Healthcare Commission after an inspection found bloodstains on walls and dust on surfaces.

• Historical debts will reach £99m at the end of the financial year next month, and the hospital has introduced a recovery plan to turn around its finances.

• A patient was recently left in agony after a surgical swab was left inside her after she gave birth by Caesarian section.

However Mr Wilson, 56, said in the interview the hospital is on course to balance its books and move on to providing some of the best care in England.

He said: "We will be working on things such as efficiency, how we get a really great service to people in the hospital, in such a way they get well more quickly and leave hospital sooner, and leave with the appropriate treatment and package of care which is comparable with the best in the country."

Mr Wilson spent 10 years working for Tower Hamlets social services, turning it from the country's worst to its best, according to the Commission for Social Care Inspection.

One of the challenges he faces is its debt. But as interim chief executive of Brent Primary Care Trust he turned a £25m deficit into a £1.5m annual surplus.

In Bromley, an independent inquiry into the debts' origins is under way and a recovery plan has trimmed the annual overspend from £25m to £18.7m for this financial year.

Next year the trust is expected to break even, and will begin repaying debts, a process Mr Wilson admits could take between 50 and 100 years.

The damning Healthcare Commission report following a visit to the Princess Royal in January was unexpected.

But, Mr Wilson claims, it has proved a blessing in disguise, and he says the hospital is now challenging the best in the country for cleanliness.

This claim will be put to the test when the commission releases its follow-up report tomorrow.

'I will get hospital in excellent shape'

The Princess Royal University Hospital (PRU) has come under fire recently. Thom Kennedy meets Bromley Hospitals' NHS Trust chief executive Ian Wilson to discuss its future.

Can you tell us a little about your background?

Most of my career has been in local authority public service so my background is as a director for social services. The last 10 years were in Tower Hamlets where I was director of social services for Tower Hamlets Council.

I was acting chief executive at TH council. I got my pension from that and retired, then I thought, I've still got plenty of public service in me. I can't work in local government any more as I have got my pension, where shall I go? I went to NHS London and they said go to Brent PCT as interim chief ex so that's what I did at the beginning of last year.

That was the most financially challenged PCT in the country at the time. I don't claim all the credit for the whole turnaround but they went from a £25 million deficit and this month they are reporting a £1.5 million surplus, so when I left Brent PCT I had a few weeks off and said to NHS London have you got another one? They said how do you fancy one of the most financially challenged acute trusts in the country?

I'm a very experienced public service manager with a strong track record of improving services and I've just transferred those skills from local authority service to the health service. When I took over Tower Hamlets social service it was the worst in the country and when I left according to the CSCI it was the best in the country.

My management team won UK management team of the year in 2005. I've got a kind of list of stuff like achievement stuff that gives me some confidence I know what I'm doing.

What can you bring from Brent into Bromley?

In general you don't get a financial turnaround by just cutting services, you get a financial turnaround by using the resources you have got in a much smarter way.

That's much more motivating for staff than just telling them you are going to hack another £10 million off the budget.

There's a principal I bring to work with all the different types of staff in that setting to say what is the best practice nationally, if we import that best practice here we will be more efficient, have higher productivity and balancing the money will drop out of the end of that process, which is a process which has the patient, the customer, at the centre.

It's about producing a good quality service rather than focusing on cuts, cuts, cuts, which isn't a useful approach.

The guy I brought in as turnaround director shares that view.

I've got him because he and I have a common view on that. We will be working on things about efficiency, how we get a really great service to people in the hospital, in such a way that they get well quicker and leave the hospital sooner, and leave the hospital with the appropriate treatment and package of care that is comparable to the best in the country.

How will you differ from previous chief executives?

It's hard, I didn't know the previous management, they had gone by the time I got here. I don't know enough about them other than anecdotes.

I know what my style is that Ive done for more than 20 years of senior management posts in the public sector, to be out with the frontline staff, listening to their concerns, communicating to them as much as I can about what our ideas are, what we want to do, why we want to do it, seeking to carry people with me, being straight with people and trying to get managers to understand it's their role both to lead and to remove impediments to day-to-day work.

I do some university teaching on leadership and that's how I teach.

Why has the hospital got such a burden of debt?

We've commissioned an independent inquiry by a man called Michael Taylor into what happened before. We will publish the findings as soon as we have them.

He has interviewed nearly 80 people including many who worked here before and he will have a much more objective view than anything I might say.

The best thing is to wait and see what that report says. He has got a very comprehensive brief to delve into all the aspects of what might have contributed to the past problems. He has left no stone unturned.

I know his work from elsewhere. He's a very skilful man who has done dozens and dozens of these types of inquiries, so I'm confident he will get to the bottom of what happened.

The public deserve an explanation and so do our staff. It felt to them like one day we were fine and the next they learnt we weren't.

What elements of the recovery plan have been implemented so far? How are things going to look this year?

The recovery plan items so far were mainly straightforward cuts and closures, wherever it was possible to do it, to run the service safely for the patient but with fewer wards or fewer staff, those opportunities have been taken. That all predates me.

Those are the elements of the plan that have been done.

The projected overspend has been reduced to £18.7 million, which is about £10 million less than was thought back in the summer.

That means the challenge for the new financial year is to have a turnaround plan that gets us to break even by the end of March 2009.

The big productivity area is length of stay in hospital.

If more people can come through the hospital successfully and safely the hospital can earn more income from its assets.

Efficiency and good value for money for the taxpayer go hand in hand with good hospital care. All the research is if you import modern practice into hospitals you reduce the length of stay, you have better outcomes for patients.

The classic example, although we already do this here, is day surgery and keyhole surgery. If you cut a big hole in somebody to operate on them they are going to take ages to recover and take up a hospital bed.

If you cut a little tiny hole in somebody and do keyhole surgery, even just with an epidural, they might walk out on their own feet the same day, they will be less at risk of infection as a result, they will be happier and have less analgesic problems.

It costs the NHS one day's work instead of four to five and the patient is hugely happy with a result and about on their own feet quicker.

You import good practice into places.

A lot of keyhole was pioneered here. It looks to us as if we could make some progress on length of stay and we only need to take one day off the stay of all the patients here between five and ten days and we've got 60 beds.

When might the hospital run on a balanced budget?

If you take the next financial year from April to March next year, the year as a whole, our projection is that we will run as a balanced budget, because the turnaround plan will kick in a few months into the financial year and we will spend nine or ten months of the year recovering.

The year after that might the hospital be running at a surplus then?

Yes, but by that point we have to start repaying the debts of all the past years of the surplus.

What will the final debt be?

£99 million. The figure currently is £18.7 million less than that.

What happens to it?

Various arrangements will have to be made to owe that to the NHS over a number of years until it is all paid back.

What sort of surplus could the hospital be running at?

It's very hard to tell, I wouldn't want to have a punt at that.

Nonetheless it could be that it takes 50 to 100 years to pay?

Yes.

Will the plan have an impact on non-medical services at the hospital?

It will improve them.

To deal with the financial turnaround we are starting with questions of performance or efficiency.

If somebody waits a number of weeks for an outpatient catscan, if we can work out how to use our catscanning facility in a more productive and cost-effective way, not only can we reduce the waiting time for your catscan but getting more value out of that kit and the people that run it.

Will there be a knock-on effect for people using the hospital too?

Yes. The performance and how long you wait for an outpatient performance, or the performance in terms of how long you wait for elective surgery, all that gets to improve.

The productivity drives improvement in all of those things.

You do know that our performance on some of our national targets is really poor at the moment so there's loads of scope for improvement.

We are good on MRSA and C-diff, on things like the four-hour target for waits in A&E or the 18-week target for referral for treatment of inpatient and outpatient we are a poor performer on those things.

It's quite apparent that there's plenty of scope for doing things better and faster because other hospitals in London and the country do those things better than we do just in sheer performance terms.

Going from average or below average to good is relatively low-hanging fruit.

There's all of us who've done this know that bit is quite straightforward, it's going from good to the best in the country that is the really difficult bit, and that requires a different set of skills, but the bit from average/below average to good is a relatively well-trodden path for most experienced managers and is not enormously difficult, and won't be enormously difficult here either.

Have you had any assistance from the PFI?

They have been really good. Not in terms of finance but in being willing to work with us to improve services here they have been great.

Knowing the problems have they agreed to restructure the contract at all?

They did restructure the contract some years ago to help. I would be surprised if having done a generous restructuring once they would do it again.

With regards to work on cleansing in recent weeks following the improvement notice they have been a really good partner and we have been doing some building work and on the national deep clean problem they have been great.

There's always going to be differences of opinion between the person who holds the contract and the contractor, that's life, but it's a good relationship now.

Was it not in the past?

I'm told, cautiously because it's anecdotal, that it had become very adversarial in the past.

Do you know in what way?

No.

Following the improvement notice, what happens if the Healthcare Commission says there's more to do?

They set another timetable, however many weeks or months or whatever's appropriate.

They will vary the improvement notice to what they say, or recommend the lifting of the notice, which is what we hope.

We've done such a lot of work, we will be disappointed if it isn't lifted.

What specific roles are the nurses doing in relation to cleaning?

In every hospital in the country nurses and healthcare assistants, the unqualified nursing staff we employ, will have roles with regard to cleaning as well as nursing, that's universal.

Classic example, body fluids from a patient in the ward, in every hospital in the country, are cleaned by nurses and healthcare assistants, not cleaners.

Most other cleaning in the ward area falls to your cleaning contract.

What was really valuable about the improvement notice was it highlighted the fact that the demarcation between what the nursing staff do and the cleaning staff do had become blurred.

And demarcation between what we as nursing management and the cleaning staff management inspected or monitored had also become blurred.

So everybody was working in good heart and good faith but the demarcations weren't clear enough and that left some areas slightly vulnerable so the improvement notice was really, really useful as it led to an almost immediate sorting out of that to the benefit of everybody.

If you go down and talk to both management and staff, nursing and cleaning staff, everyone is really crystal clear about what everybody is meant to be doing every day, and who is meant to be monitoring it every day. So that's been dead useful.

Now, my view is that the cleansing of this hospital is comparable with the best in the country, which is what people of Bromley can reasonably expect.

If you say to the people out there do you want your loved ones to be treated in an average hospital or in one that's the best in the country, the people out there aren't going to plump for average.

If my family's in this hospital I don't want average care I want great care in a hospital that's as clean as the cleanest in the country, and I think that's a reasonable standard and I think now we can measure up to that standard, and I think on cleansing now we can measure up to that standard and the inspection notice has helped us get there really quickly, which is great.

What changes have been made since the notice was put in place?

All the written demarcation as to who does what has been looked at, reviewed, checked to make sure it's right, and every member of staff involved in any way, shape or form has been met with or trained in who is meant to be doing what and what the acceptable standards are. Similarly, on the managerial side as to who is meant to be monitoring what's happening when. That's the most important bit of it.

We have changed the use of some type of equipment and changed the scheduling of some of the cleaning, we've done some repair work that was scheduled anyway but brought forward as it was affecting cleanliness issues.

It has been a real shot in the arm, it's great.

Did you expect what happened with the Healthcare Commission?

No, we didn't.

What were you expecting to hear as and when they did the inspection?

We fully expected a clean bill of health at that point as everybody believed they knew what they were meant to be cleaning, and everybody monitoring thought they knew what they were meant to be monitoring.

People going round monitoring thought they were looking at what they were meant to be looking at and it was fine.

The people doing cleaning thought 'I'm doing my bit, I know I'm meant to be cleaning that every hour or whenever they were scheduled'.

People generally thought they were doing what they had been asked to do. What hadn't been spotted was there was just this osmosis or something that led to the demarcation just starting to not be right with regards monitoring and the actual cleaning.

It never meant places didn't ever get cleaned, as people would see a place that needed cleaning and would clean it but the sense of this has to be cleaned, by me, every fourth hour without fail or every day or week without fail, had slipped in some way with regards a small percentage of things and that was enough for when they came round to see a small number of faults that were sufficiently serious faults to serve a notice.

My view is it's absolutely invaluable, really useful.

We are not many weeks on, and we are probably as good at cleaning as anybody could reasonably expect a hospital to be, anywhere in the country.

We've got a few bits of building work we are doing as we do the so-called deep clean of the wards, and they will be done over the next six weeks, then we really will have the place in excellent shape.

Some things the report brought up were things like blood stains. That surely shouldn't take demarcation?

Well, no. What the Healthcare Commission saw as a thick layer of dust by the way is not your or my thick layer of dust, it is a very thin layer of dust, but they are right to flag it.

The places they found them were high-level grilles eight foot up the wall, and on the bars of the grill would be dust.

There shouldn't have been, we are not proud of that, but it wasn't an area in the eyeline of the people working day to day.

If there'd been dust on a window ledge somebody would have thought 'that's dusty, that's not my job but I'll dust it anyway', even though demarcation had gone wrong on that window ledge.

The blood spots were in the emergency assessment unit which is a place where we are treating acutely ill people.

In some of those cases there will be blood from those people.

They weren't talking about a great swathe like something out of the Sopranos up the wall, or CSI, they were talking about some very small blood spots.

Now, you might think why would any of us worry about small blood spots but you know, it only takes one microscopic piece of blood to potentially create a danger for a patient so they were right to flag it, and we are right to have cleaning regimes in places like the EAU which clean much more frequently because we know there's much more blood in the EAU or the A&E.

If you look at the schedule, A&E have the most cleaning because there's going to be the most potential for needing it.

It's not a case of cleaning every ward the same, why would it be?

You would've expected there to be blood in the EAU but would expect it to be cleaned up in a four-hour period and it hadn't been.

It wasn't buckets of blood, it was a few spots.

Were there any renegotiations of contracts with United Healthcare following the report?

We didn't renegotiate the contract, we had a mutual interest in getting this right and getting it right quickly.

They participated very well in the sort of discussions I've just described about the clarification of who does what.

That was done over days not weeks, as that was at the heart of the problem.

The detail followed from those issues.

The details of why is there dust on that corner of that rail, or why is there blood on that trolley.

Why is there that mark on that bed and we're not sure what it is.

All that followed from the sense that the staff at the frontline weren't absolutely sure about the demarcation.

We of course thought the demarcation was fine, otherwise we would have fixed it.

It's fair to say I had only been here four weeks when they came so I feel slightly like I don't have to be the apologist for it.

What is the relationship like between medical and non-medical staff?

It's good, it's a good sense of teamwork. Bromley hospital is full of decent, fair and open-minded people who work here, I think they get along with each other very well.

They know each other on the wards, it doesn't really matter very much who their employer is.

Was any blame apportioned after the Healthcare Commission report?

People were interested in responsibility, how are we in this and who is responsible was something worth discussing, not to be blamey, but to learn what we needed to fix and how we were going to fix it.

I don't think anything was going to be gained in terms of the pace we were going to solve this by mutual recrimination and blame.

That would delay solving it.

I said let's work with this to get it fixed, I don't want another day with a hospital like this, and that was the spirit at which we went at this.

People have spoken to us about superbugs. What systems are in place to combat these?

We do exactly what every decent hospital in the country does, and follow national guidance.

Our C-diff and MRSA rates are in line with the national targets the government sets and we are quite unusual in London in being on target, three-quarters of London hospitals aren't.

In terms of actual infection control this hospital is a success story, and the strategic health authority acknowledge that.

In terms of what we do for infection control we are good at it.

One reader's mum contracted pneumonia in a four-bed room. She believes that had she been in one-bed it could have been avoided.

Short of building a hospital that is all single rooms, and there isn't one outside the private sector in this country, I don't know what you could do with that.

Is there any plans for extra single rooms?

No. We are well provided with single rooms here.

Each ward has at least four, and in some cases eight single rooms, we are well provided compared with many hospitals nationally and we use them sensibly.

What do you feel the knock-on effect of Picture of Health consultations will be for PRU users?

In all the options of Picture of Health the PRU is a major admitting hospital.

That's the top of the tree in terms of hierarchy of hospitals, so I think the future in terms of what we offer the people of Bromley is very rosy.

In all three options this hospital comes out well. We are a top-level service provider, that's good from this hospital's point of view.

In terms of utilisation of the hospital, how will PRU be affected when you are taking patients from other maternity units?

Some work is moving out and some is moving in.

Elective surgery, as it stands and we are only in consultation at the moment, that isn't done here.

The surgery wards here that have elective surgery will have moved off somewhere else, and that frees up space for whatever you want to bring in, whether it's maternity or more acutely ill patients, both of which are in PoH as it stands.

The number of patients remains the same number of patients, it doesn't miraculously get fewer. Overall it all has to balance.

Do you think Picture of Health considers the PRU will be taking the same amount of people? Will the PRU be able to maintain the same amount of patients coming in?

The PRU will be running as a fully utilised site in all variations of PoH. The only variation is what is done in our beds, what is done in a PoH. This is a very valuable asset. To not fully utilise it wouldn't make much sense really.

We've had a lot of letters regards stories saying the consultation document is confusing and biased.

It's not my consultation, I'm a consult too. The four PCTs are running the consultation, it's a question for them.

Do you put your trust in the local health authority or use private healthcare?

I have never used private healthcare in my life, and nor have my family.

I live in Lewisham borough, and I use Lewisham Hospital when I need it, and Guys.

Why did you decide to take on the job?

I took it on because it's what I do. What I do is go into NHS organisations that need a lot of managerial help and provide help and expertise.

More personally, it's because I really care about great public services.

I don't understand why people shouldn't aspire to having brilliant public services, and I've spent more than 30 years of my life trying to provide public services that delight and empower people.

So long as I'm still working that's what I'm going to be doing.

Have the local media been overly critical?

No. The media reflect public concern and there's completely legitimate public concern, of course there is, and it will be a little while yet before public confidence is fully restored, because the public want evidence.

They want to see the improvement notice lifted, and our performance improve on four-hour A&E and 18 weeks improve first to the national average and then into the top quartile of national performance.

They will want that evidence before they become fully confident again.

They want to see the evidence that we are not financially bust and are running sensibly within our own resources.

The media are accurately reflecting legitimate public concern.

You have said you hope the PRU can become one of the best hospitals in the country. How ambitious is that?

It's completely possible. I've had a guy working with me here called Dr Simon Walford, a national expert in A&E services, which is an area where currently we are performing poorly on national indicators. He says 'I have got the building, the equipment, the superb staff to become a top performer on A&E'.

If we organise ourselves properly and change the way we do things and apply our resources properly that's what we will become.

His view is that's not an enormously long haul for us, maybe six months.

There's plenty of other parts of the hospital where to aspire to being the best in the country is realistic, and there are one or two areas where individual doctors are already nationally acknowledged for their skills in their field, although if I name one I'll forget one who's been acknowledged worldwide as one of the best practitioners.

Does the same thing apply non-medically?

People knock the PFI deal but the deal on the technology is very positive.

When our technology becomes obsolete within the deal it gets upgraded.

We don't offer more money, they undertake, when the latest echocardiogram equipment becomes obscelete, and there's a new generation of three-dimensional echocardiograms, the new generation come in. When you get treated at this hospital, the technology that's being applied is absolutely second to none, it's world class.