09.02.18
Kirkup: Critical widespread trust failures offer urgent lessons across the NHS
An independent review into the “widespread failings” of a community health trust has made a series of recommendations for NHS Improvement (NHSI), the CQC, NHS England, the Department of Health & Social Care and trusts.
The review, commissioned by NHSI, looks into the issues at Liverpool Community Health NHS Trust (LCH) between November 2010 and December 2014 after a 2013 CQC inspection identified a range of serious issues at the trust, requiring immediate response to systemic failings.
With staff scared to speak up due to a culture of bullying and with major incidents left ignored, the review found that external overview of the trust could have reduced avoidable harm by intervening earlier – but instead let the service problems fester for at least four years.
Whistleblowing concerns by staff at the trust were raised with Rosie Cooper MP, who had witnessed staff under significant pressure whilst her father was a patient in an intermediate care ward run by the trust.
Conducted by Dr. Bill Kirkup CBE, the review also examines the oversight of the trust by the NHS Trust Development Authority, NHS England and commissioners.
The review found that the new, large trust was established from scratch with “an inexperienced board and senior staff,” and that the board was in denial of the trust’s failings.
“It is clear to us that the reaction of the trust board to this gathering crisis in services was based on denial. The management team was still focused predominantly on becoming a foundation trust (FT), and reports of service problems were not only a distraction, they would adversely affect the assessment of the trust’s capability of achieving their goal,” the report said.
It later added: “The level of denial by the leadership of the trust that there were problems does not align with the commitment to take personal responsibility for their actions.”
The review claims that there was inadequate scrutiny because the trust was regarded as low risk, which was in part due to the nature of the services it provided. Consequently, patients suffered “unnecessary harm” over several years, and staff faced unnecessary stress.
In some cases, staff were bullied and harassed when they tried to raise concerns over the deterioration in patient services.
“Objectives to reduce inequalities and improve health were also undermined by the cost-cutting within the organisation, and staff have certainly indicated a culture of bullying and harassment that cannot have made them an employer of choice,” the document added.
According to the report, the trust was a “dysfunctional organisation from the outset.”
It found that the trust “acted inappropriately in pursuit of FT status, setting infeasible financial targets that damaged patient services,” and that the board failed to recognise that the trust was out of its depth.
‘Grossly deficient’ cost-saving assessments
In order to address these self-imposed cost pressures, as well as external ones, the trust aimed to make an annual cost improvement of 15% in a year – despite the upper limit of this kind of programme generally being regarded as 4% – and the review found that there was no evidence that the management team or board recognised the substantial risk that this posed.
Proposed cost improvements mainly involved staff reductions, which were subject to a quality impact assessment – a process which should have identified adverse effects on services, and if and how they could be mitigated.
However, the review found that the assessments were “grossly deficient,” failing to identify “obvious consequences of most of the proposals that were implemented.”
Clinical governance systems and risk management systems were also “unclear and ineffective.”
A significant responsibility was placed on the nurse director, who, for at least part of the period, was also the trust’s chief operating officer, and therefore responsible for achieving the cost improvement programme. The review found that this resulted in the serious risk of the cost improvement programme not being recognised.
Despite the efforts of staff to compensate for reduced numbers, the incidents of patient harm, such as pressure ulcers and falls, rose.
Other incidents, some of which were serious, should also have been reported and investigated, but investigators heard claims that “reporting was discouraged, investigation was poor, incidents were regularly downgraded in importance, and action planning for improvement was absent or invisible.”
Johanna Reilly, chief operating officer of LCH NHS Trust, apologised on behalf of the trust for its failings, but promised that significant progress has been made.
“It is also worth noting that from 1 April 2018, subject to approvals LCH NHS Trust will cease to exist as it becomes part of Mersey Care NHS FT,” she added.
“We will work tirelessly to pursue and develop a fair and supportive culture that enables all staff to deliver the best care possible for the people we serve.”
Major recommendations
As part of his review, Kirkup made a series of recommendations for the major national health bodies and the trusts currently providing services that used to be run by LCH.
For example, NHSI should take note of the level of experience of employees when making trust board appointments, as well as the level of risk in the trust, and should ensure a “system of support and mentorship” for board members.
Regulators and oversight organisations, such as the CQC and NHS England, should also take into account the cumulative impact of relevant factors when assessing the level of risk a trust faces – including a newly established organisation, an inexperienced board, cost improvement targets and service acquisitions.
They must also review how they work together jointly at regional and national level; improve the use of information and soft intelligence; and ensure that performance and other service information is properly recorded and communicated during both local and national reorganisations or reconfigurations.
Meanwhile, the trusts that have taken over LCH’s services should review the handling of previous serious incidents to make sure they have been properly investigated, as well as review the handling of whistleblowing cases urgently.
Similarly, NHS England and NHSI must review the reconfigured LCH services after a year to make sure they are now safe and effective.
Ian Dalton, chief executive of NHSI, said: “The report has important lessons for our organisation and the whole of the NHS. We will carefully consider its findings and take appropriate action.
“We expect to respond fully to the review’s findings by late March 2018.”
(Top image C. Peter Byrne, PA Wire)
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