From the outset, Sir Bruce insisted on an unprecedented level of transparency intended to ensure honesty and accountability to its biggest stakeholders, the patients and public whose confidence needs rebuilding. He also wanted us to work with all levels of staff as well as patients and the public, to look beneath the skin of the Trust and its services.
Challenge the Trust and the system
From the start, we sought to be challenging but fair to the trust, identifying problems and making clear recommendations for quality improvement where appropriate yet also supportive – avoiding a needlessly judgmental style. This may seem rather lost in the political and media storm following publication, but read the report and you will see a rather more measured set of recommendations with a clear challenge back to the local health system leadership to contribute to the required improvement. It’s all there on the NHS Choices website: Data sets, findings, investigator biographies, risk summit videos (gripping footage – if only for the body language) and recommendations.
The people were able to see from top to bottom
Our investigation teams were experts from diverse backgrounds. Senior, current clinical and managerial experience together with junior members of staff teamed up with a knowledgeable group of service users and members of the public. A team reflective of the services they inspect; able to see, hear and sometimes smell good examples as well as inconsistencies in care or patient experience. We all contributed by taking a few days away from our own frontline active roles. We came, saw, asked, triangulated and agonised over context and balance both practical and ethical. We learnt a great deal to take home. It is amazing what you see from the outside.
Depth and breadth of remit
The key principle here is of an appreciative enquiry with a desire to make sense of what we saw in front of us without bias or expectation. This was blended with rigour expecting strong processes to be in place to protect patients and support staff. The review was guided by a series of key lines of enquiry (KLOE), determined by the panel from the extensive data set made available. These covered all of the most important areas of Trust service delivery: Governance and assurance, clinical service operations, quality and improvement, patient experience and complaints and workforce. Each KLOE had the effect of guiding the investigation but didn’t constrain panel members from following ‘the scent’ for information or evidence gathered allowing an expansion or refinement during the visit. The lack of boxes to tick allowed the team to focus on what they saw.
The people we spoke to
A lot of time was spent listening to patients and the public, sometimes two or three public meetings were held, some over running for hours to allow the public sufficient time to speak. We listened to staff individually, in forums and in focus groups. These are two huge, often ignored, founts of knowledge and experience. We often claim to know that the engagement of well trained staff is a very big key to safe delivery of quality services. We should learn to do this properly and regularly, providing the correct environment for people to speak honestly.
Leadership and quality governance: Board to Ward
At last, an assessment process that recognises that staff and patients will only be able to do their best working in a system and culture that allows and encourages them to deliver their best; that recognises where inherent risks in healthcare are identified and mitigated; where continuous improvement must begin. We were able to question the top leaders in the Trust, examine culture and quality governance and identify improvement areas. Quality must be owned by the Board leadership.
Every panelist took some time away from their diverse day jobs and supported the process, bringing their own knowledge as leaders to deepen the quality of each review. They also learned themselves. Maybe we should celebrate this as something only the NHS could do?
The new Chief Inspector of Hospitals, who joined us on a number of the review visits, has chosen this methodology to inform the design of his own forthcoming inspectorate methodology. I’m sure he is right and am sure he will want to take the principles of transparency, honesty and a relevant team with him. It also has wider potential as a model for assessing services across systems rather than single hospital Trusts, such as stroke or cancer services or vascular networks. You could even collaborate with neighbouring Trusts to evaluate each other’s services.
The review has shown that it’s possible to carry out a rigorous yet supportive and transparent review of services that leads toward clear and achievable improvement. It has severely underlined the responsibilities of NHS leaders in the promotion and assurance of quality governance and continuous improvement. That’s a challenge of trust and respect that we should all rise to as leaders with the best care of patients at the centre of what we do.