1-2 July 2014
During a routine inspection
Letter from the Chief Inspector of Hospitals
The key question we were asked to consider whether Mid Staffordshire Hospital NHS Foundation Trust (MSFT) is currently providing safe care and whether safety was likely to be sustainable in the future. We were aware that the planned date for the dissolution of MSFT and transfer of responsibility for services to University Hospital of North Staffordshire NHS Trust (UHNS) and Royal Wolverhampton NHS Trust (RWT) is 1 November 2014. We therefore considered whether safe provision of services was likely to be sustainable over the next four months and beyond that over winter 2014/15.
Our approach
To undertake this task within a very short timescale we modified our new approach to inspection of acute hospitals. We concentrated particularly on the first of CQC's five key questions i.e. Safety. Within this we looked very closely at staffing levels for nurses, doctors and allied health professionals in key clinical services and the approaches that Trust Special Administrators and Mid Staffordshire Hospital NHS Foundation Trust has made to recruit and retain staff. We also looked at the impact of any deficiencies in staffing levels on the quality of care being delivered by staff at MSFT. Finally we considered the leadership of services at MSFT.
During the pre-inspection phase we looked at the report from the Trust Special Administrators (TSAs) regarding future configuration of services currently provided at MSFT. These recommendations have been accepted by the Secretary of State for Health and we were not asked to reopen the debate on these recommendations. Rather, the report provided us with the agreed direction of travel for different clinical services. We are also aware that a further review into the configuration of maternity services is being commissioned. We reviewed the safety and sustainability of services at this trust in this context.
We were given access to the minutes of the Sustaining Services Board, chaired by the TSA representative, which brings together leaders of the local health economy around MSFT and to a copy of the due diligence report commissioned by the Board of UHNS. The Chief Executive of MSFT and her staff were extremely helpful in providing detailed information on current and projected staffing levels and other recent performance management information for the trust.
In this process, we are not providing ratings on the trust as we normally would do. This is deliberate and reflects both the bespoke nature of the remit and the planned disaggregation of the trust in November.
An overview of our findings
The commitment of staff at all levels to the delivery of high quality care at MSFT was evident throughout the hospital. However, it is important also to recognise the degree of fatigue reported by staff. This relates both to the relentless external scrutiny focused on MSFT and from uncertainty about the future.
The trust is facing major difficulties in recruiting and retaining medical and nursing staff both because of the continuing uncertainties about the future and because of the previous poor reputation of the trust outside the local area. These factors are creating a large destabilising influence across the organisation.
The senior managers at MSFT, including the Chief Executive, are spending inordinate amounts of time ensuring that individual nursing shifts are adequately filled and that sufficient numbers of medical staff will be available for different services. To date they have just been able to do this, but the emphasis here is on the word just. This has resulted in a significant reliance on temporary medical and nursing staff, which has a resultant impact on permanent staff working in the relevant clinical areas. In addition, there is an almost complete dearth of formal medical service level clinical leadership at MSFT. While additional staff have been supplied by UHNS in some clinical areas, in other areas the movement of staff has been from MSFT to UHNS.
Our inspection team members judged that safe care is currently being delivered in each of the clinical areas except for medical care which required some improvement. Staffing levels are only just adequate in some areas, particularly on the medical wards and of these, the winter escalation ward, (ward 11) was still open and gave the most cause for concern. Medical and nursing staffing pressures make this ward unsustainable.
The inspection team members were, however, much less assured about the sustainability of some services, even over the next four months. Should staffing levels fall by even one or two people in some key posts, services would become unsafe. The only option for handling such an eventuality identified to us either by the TSA or the trust management would be to reduce the bed base and almost certainly to restrict admissions to the hospital (unless flow through the hospital can be substantially improved). Indeed there have already been occasions when the West Midlands Ambulance Service has been asked to divert emergencies to UHNS or RWT. Undesirable as this is, this does indeed appear to be the only option available. The fragility of the provision of acute services cannot be overemphasised
The TSA and the trust management have proposed a reduction in the opening hours of A&E as a means of reducing the burden on acute services and thus maintaining safety. My inspection team had concerns about this approach. In particular they were concerned that it might not achieve the desired reduction in emergency admissions to the hospital and that it might render the junior doctor rotas unviable. This would at the very least need to be discussed with colleagues at Health Education England.
Looking beyond the planned date of transition in November 2014, inspection team members were unanimous in their view that services would be unsustainable should any degree of winter pressures arise. It is therefore imperative on safety grounds that the transition should not be delayed.
Transition
We were both surprised and very concerned that a clear transition plan has yet to be developed to ensure the safe transition of responsibility for clinical services to the agreed model of care over the next four months. This clearly requires full involvement of MSFT and other organisations in the wider health economy. Although the Sustaining Services Board has provided a useful forum for bringing together the relevant stakeholders it is not a decision making group and has no authority to take action. In addition the workforce at MSFT needs clarity as soon as possible about what is going to happen and when. The current uncertainty is contributing to the fatigue and fragility amongst staff. The transition plan should therefore include a commitment by the acquiring organisations to actively support medical and nursing staffing levels at Mid Staffs over the next four months so that services remain safe.
It is now imperative that a clear and timetabled transition plan should be developed and implemented without delay. This should set out the steps that will be taken to ensure services remain safe, effective, caring and responsive to patients’ needs. Leadership responsibilities and accountabilities need to be clearly defined. This will require high level input and commitment from TSA/MSFT, UHNS and RWT and from CCGs and WMAS. No single organisation can achieve this on its own. High level oversight from Monitor and TDA, as the organisations which oversee the various providers will be essential.
Yours sincerely
Professor Sir Mike Richards
Chief Inspector of Hospitals