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How it feels to nurse at a ‘failing’ trust

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Nurses are critical of the system that deems trusts ‘failing’. Richard Staines finds out why

THE HEALTHCARE Commission’s annual health check, brought in two years ago, involves assessing and rating the performance of each NHS trust in England. It was intended to provide a more comprehensive review system than the star ratings scheme it replaced.

It relies on trusts assessing their services against national targets. Results are cross-checked and audited by the commission and published on its website. Performance is rated in two categories: ‘quality of services’ and ‘use of resources’. Trusts are rated ‘excellent’, ‘good’, ‘fair’ or ‘weak’.

There are also spot checks, assigned in some cases randomly and in some cases if the commission feels hospitals have not been accurate in their self-assessment.

Trusts deemed to be failing are served with improvement notices and given deadlines to improve aspects of their services. Failure to do so can mean the commission launches an intervention to improve standards by a certain time. If interventions fail, the health secretary can call for special measures, such as imposing a new management or even closing the trust.

Northern Devon Healthcare NHS Trust was one of just four that has been found to be ‘weak’ in both quality of services and in use of resources for two years running. It ‘failed’ against a series of the commission’s core quality of care standards, including failing to implement NICE guidelines on interventional procedures and patient dignity standards.

But Lesley Trute, a staff nurse at the trust, said the rating does not give the full picture about the trust’s services. Not meeting the dignity standard – a lapse she says occurs because high demands mean wards become mixed during busy periods – was particularly galling for staff.

Ms Trute says: ‘I was very annoyed that we failed the dignity part. We have a very busy ward and take patients from A&E – we have a mixture of patients. Sometimes patients may be mixed because of a lack of bays but we always ensure they are treated with dignity.’

The new ratings system is bureaucratic, says Ms Trute. ‘The systems that the Healthcare Commission uses don’t really reflect what is happening. You can tick boxes and make sure systems are in place. The nursing staff are doing what they should be doing on the wards – but the commission says the boxes are not ticked.’

Despite two years of bad ratings and a review of the trust’s services, Ms Trute says that morale has begun to return because management ensured no redundancies took place during the financial turnaround.

‘The nursing staff are terribly professional and we can see what management are trying to do – we have stood by them. We are now turning the corner and we are glad we have stuck by it,’ says Ms Trute.

Another trust at the wrong end of the commission’s assessment is one of the largest in the country – Leeds Teaching Hospitals NHS Trust.

According to local nurses, the review system is particularly unwieldy for large organisations. It is preoccupied with systems and procedures on which it is often difficult to gather data, they say.

Leeds fell short on targets such as the 26-week maximum wait for inpatients, waits from referral to treatment for urgent cancer cases, and re-booking of operations cancelled for non-clinical reasons.

But nurses defend the trust’s care standards. Rachel Binks, RCN critical care adviser, who worked at Leeds Teaching Hospitals NHS Foundation Trust before moving to nearby Airedale NHS Trust around five years ago, says: ‘If one of my children was sick, I would take them there because the standard of care is wonderful.

‘The service quality is fantastic but the trust is so huge that it is very difficult to manage it. When you are trying to meet standards set by the Healthcare Commission and they want evidence, it can be difficult to pull it together.’

Ms Binks says that organisations that are struggling financially usually find their clinical ratings also fall. ‘It is all about finance – if you are poor on financial management, it really pulls you down,’ she says.

Nurses at other ‘failing’ trusts reveal that quality of care has been affected by the tough NHS financial regime. Scarborough and North East Yorkshire Healthcare NHS Trust scored ‘weak’ for both quality of care and use of resources. Nurses there have already fought a campaign against massive job cuts and service reductions, which resulted in the health authority temporarily calling off a debt of £20.5m.

Finance is still a problem for the hospital, say nurses, and issues such as low nurse-patient ratios are now affecting patient care. Suzanne Meek, a senior sister at the outpatient department, says she does not blame management for the problems.

‘We are working at very limited staffing levels. Senior nurses have already raised concerns with the board regarding patient safety and patient care being compromised,’ she says, adding that the only way to solve the problems is to fund the hospital properly.

Only then will the trust be able to comply with national standards in areas such as waiting times for outpatients and access to chest pain clinics, she says.

‘It stems from finance. The government promised everyone that healthcare across the country would be given an equal share of resources. We do not get a fair share of funding from the strategic health authority. They give us £55.34 less per head per capita than other trusts in the area.’

Ms Meek was unsurprised that the trust’s ratings were so poor – but added that it helped make the case for improved funding.

She says: ‘If you don’t raise awareness, then the public will think we are running an extremely bad service. But most patients want to be treated at their local hospital.’

Nurses at the trust are fearful because Yorkshire and Humber SHA has not written off the hospital’s historical debt completely. It has merely been ‘parked’ until the end
of the financial year, when it will be reinstated unless the trust remains in financial balance.

‘The public might think that there is not a finance problem but it is hanging over us like the Sword of Damocles,’ says Ms Meek.

‘We are failing because we don’t get enough money. You can cut right back to the bone but now we are at the marrow.’

It is clear that, according to nurses, the health checks are an unfair reflection of care standards, especially given the extremely difficult circumstances under which staff at some of the trusts are having to work.

Moves to include Essence of Care benchmarks in the checks from next year may alleviate criticisms that the system promotes a ‘tick-box’ mentality (NT News, 6 February, p2). But there may still be a long way to go before the checks reflect nursing standards accurately

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Northern Devon Healthcare NHS Trust Rated ‘weak’ on the core standards section, including:
- patient dignity;
- using NICE guidance on interventions;
- staff training;
- risk assessments;
- promoting patient feedback.

Leeds Teaching Hospitals NHS Trust Rated ‘weak’ on existing national standards section, including targets on:
- maximum wait of 26 weeks for inpatients;
- maximum two-month wait from urgent referral to cancer treatment;
- operations cancelled for non-clinical reasons.

Scarborough and North East Yorkshire Healthcare NHS Trust Rated ‘weak’ on meeting existing and new national standards, including:
- a maximum 13-week wait for outpatient appointments;
- targets in treating myocardial infarction within an hour.
- two-week waits for chest pain clinic access.


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