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Wednesday 17 July 2013: The Keogh Review process matters as much as the outcome, and a thought about the NHS England CEO job

Professor Sir Bruce Keogh has a well-earned reputation as nobody's fool. His report into the 14 hospitals he was asked to investigate at the launch of the Mid-Staffs Public Inquiry report is widely acknowledged as a fine piece of work.

Sir Bruce's covering letter to SOS Jeremy 'Bellflinger' Hunt bears quoting extensively, as I have done below, together with his list of ambitions and actions.

However, what the review concludes is certainly rivalled in importance by the way in which the review worked. ('It ain't what you do; it's the way that you do it'.)

Its shrewdest move was the involvement of junior doctors, early and often. Junior doctors are not only going to be running the shop in less years' time than we might think, they are also not yet desensitised to locally acceptable practices. Their rotation between jobs and institutions gives them valuable fresh perspective.

Sir Bruce and colleagues took full advantage of this: clever them.

Likewise, clever them for not being afraid of patients as a key part of providers' self-policing.

The use of the resource of patient feedback (if organisations can stop acting defensively as a knee-jerk response to criticism) could avoid the repetition of serious errors or failings in patient care.

The old-school, bog-standard 'lessons will be learned' statement doesn't cut it, and indeed never actually did: the NHS is going to have to start proving that change has happened and lessons were learned, if Robert Francis' "tsunami of public anger" is yet to be averted.

And finally?

The chief executive job of NHS England probably doesn't look very attractive to Sir Bruce. But having seen this report on top of what we already know, I would be looking for two candidates to share the job.

Professor Sir Bruce Keogh would be the best candidate for the medical part of the job.

The question after that is about the other part of the job: who would provide a complementary skill-mix?

Extracts from Professor Sir Bruce Keogh's letter to SOS Jeremy Hunt
"The NHS embodies the social conscience of our country. Every week, our NHS positively transforms the lives of millions of people and we should be deeply proud of this fact. Sadly, there are times when the NHS falls well short of what patients and the public rightly deserve. The harrowing accounts set out by Robert Francis in his two reports into the failures at Mid Staffordshire NHS Foundation Trust highlight the lasting physical and emotional damage we can cause to patients and their families when we get things wrong and fail to make quality our primary concern.

"Our NHS is the only healthcare system in the world with a definition of quality enshrined in legislation. It is simple. An organisation delivering high quality care will be offering care that is clinically effective, safe and delivering as positive an experience as possible for patients. These are not unreasonable expectations. The NHS should be good in all three. Being good in one or two is simply not good enough.

"We found pockets of excellent practice in all 14 of the trusts reviewed. However, we also found significant scope for improvement, with each needing to address an urgent set of actions in order to raise standards of care.

"These organisations have been trapped in mediocrity, which I am confident can be replaced by a sense of ambition if we give staff the confidence to achieve excellence. This is consistent with the ambitions that I know the new clinical commissioning groups have for their local populations and the legal duties they have to secure continuous improvements in the quality of services provided to patients.

"So, I was never interested in simply confirming whether or not there were problems at these trusts. They knew they had problems, which they have tried but struggled to address. I was keen to provide an accurate diagnosis, write the prescription and, most importantly, identify what help and support they needed to assist their recovery or accelerate improvement.

"... Transparency has been key to this process. Every aspect of these reviews has been conducted in the most transparent way the NHS have ever seen, with everything published on NHS Choices, from the data used to inform the reviews, videos of presentations by the review panels to the risk summits and the subsequent improvement plans. For these hospitals the public have now become not just informed participants in the process, but active assessors and regulators of the NHS. This represents a turning point for our health service from which there is no return.

"... (on barriers to high-quality care)
 the limited understanding of how important and how simple it can be to genuinely listen to the views of patients and staff and engage them in how to improve services. For example, we know from academic research that there is a strong correlation between the extent to which staff feel engaged and mortality rates;
 the capability of hospital boards and leadership to use data to drive quality improvement. This is compounded by how difficult it is to access data which is held in a fragmented way across the system. Between 2000 and 2008, the NHS was rightly focused on rebuilding capacity and improving access after decades of neglect. The key issue was not whether people were dying in our hospitals avoidably, but that they were dying whilst waiting for treatment. Having rebuilt capacity and improved access, it was then possible to introduce a much more systematic focus on quality. But more clearly needs to be done to equip boards with the necessary skills to grip the quality agenda;
 the complexity of using and interpreting aggregate measures of mortality, including HSMR and SHMI. The fact that the use of these two different measures of mortality to determine which trusts to review generated two completely different lists of outlier trusts illustrates this point. However tempting it may be, it is clinically meaningless and academically reckless to use such statistical measures to quantify actual numbers of avoidable deaths. Robert Francis himself said, ‘it is in my view misleading and a potential misuse of the figures to extrapolate from them a conclusion that any particular number, or range of numbers of deaths were caused or contributed to by inadequate care’;
 the fact that some hospital trusts are operating in geographical, professional or academic isolation. As we’ve seen with the 14 trusts, this can lead to difficulties in recruiting enough high quality staff, and an over-reliance on locums and agency staff;
 the lack of value and support being given to frontline clinicians, particularly junior nurses and doctors. Their constant interaction with patients and their natural innovative tendencies means they are likely to be the best champions for patients and their energy must be tapped not sapped; and
 the imbalance that exists around the use of transparency for the purpose of accountability and blame rather than support and improvement. Unless there is a change in mind set then the transparency agenda will fail to fulfil its full potential. Some boards use data simply for reassurance, rather than the forensic, sometimes uncomfortable, pursuit of improvement".

The Keogh Report - An achievable ambition for improvement
Having conducted these reviews across 14 hospitals, it has been possible to identify some common challenges facing the wider NHS. Below I have set out my ambition for improvement which seeks to tackle some of the underlying causes of poor care.

I want to make significant progress towards achieving this ambition within two years.

Ambition 1: We will have made demonstrable progress towards reducing avoidable deaths in our hospitals, rather than debating what mortality statistics can and can’t tell us about the quality of care hospitals are providing.

Based on: This review has shown the continuing challenge hospitals are facing around the use and interpretation of aggregate mortality statistics. The significant impact that coding practice can have on these statistical measures, where excess death rates can rise or fall without any change in the number of lives saved, is sometimes distracting boards from the very practical steps that can be taken to reduce genuinely avoidable deaths in our hospitals.
Mortality outliers are characterised by the sub-optimal way in which emergency patients are dealt with, particularly at the weekend and at night.

 All trusts should rapidly embed the use of an early warning system and have clinically appropriate escalation procedures for deteriorating, high-risk patients - in particular at weekends and out of hours. Commissioners and regulators should seek assurance that such systems are in place.
 I have commissioned Professor Nick Black at the London School of Hygiene and Tropical Medicine and Professor Lord Ara Darzi at Imperial College London to conduct a study into the relationship between ‘excess mortality rates’ and actual ‘avoidable deaths’. This will involve conducting retrospective case note reviews on a substantial random sample of in- hospital deaths from trusts with lower than expected, as expected and higher than expected mortality rates.
 This study will pave the way for the introduction of a new national indicator on avoidable deaths in hospitals, measured through the introduction of systematic and externally audited case note reviews. This will put our NHS ahead of other health systems in the world in understanding the causes of and reducing avoidable deaths.

Ambition 2: The boards and leadership of provider and commissioning organisations will be confidently and competently using data and other intelligence for the forensic pursuit of quality improvement. They, along with patients and the public, will have rapid access to accurate, insightful and easy to use data about quality at service line level.

Based on: This review found that providers and commissioners are struggling to understand and take full advantage of the enormous and very rich set of data available on quality, as it is held in a fragmented way across the NHS and difficult to use to benchmark performance. We also found a deficit in the high level skills and sophisticated capabilities necessary at board level to draw insight from the available data and then use it to drive continuous improvement.

Too often, boards were honing in on data that reassured them they were doing a good job, rather pursuing data that revealed inconvenient truths, thereby missing opportunities for improvement.

 All those who helped pull together the data packs produced for this review must continue this collaboration to produce a common, streamlined and easily accessible data set on quality which can then be used by providers, commissioners, regulators and members of the public in their respective roles. Healthwatch England will play a vital role in ensuring such information is accessible to local Healthwatch so that they and the consumers they serve can build a picture of how their local service providers are performing. The National Quality Board would be well placed to oversee this work.
 Boards of provider organisations - executives and non- executives - must take collective responsibility for quality within their organisation and across each and every service line they provide. They should ensure that they have people with the specific expertise to know what data to look at, and how to scrutinise it and then use it to drive tangible improvements. Over the last decade, many hospitals in the United States have recognised the importance of this by creating board level Chief Quality Officers. Creating a new board role is not essential, but having someone with the breadth of skills required is.
 NHS England, the NHS Trust Development Authority and Monitor should work together to streamline efforts to address any skills deficit amongst commissioners, NHS Trusts and NHS Foundation Trusts around the use of quantitative and qualitative data to drive quality improvement.
 I will ensure that the requirements for Quality Accounts for the 2014-15 round begin to provide a more comprehensive and balanced assessment of quality.

Ambition 3: Patients, carers and members of the public will increasingly feel like they are being treated as vital and equal partners in the design and assessment of their local NHS. They should also be confident that their feedback is being listened to and see how this is impacting on their own care and the care of others.

Based on: Involving patients and staff was the single most powerful aspect of the review process. Patients were key and equal members of review teams. Well-attended listening events at each trust provided us with a rich understanding about their experiences at the hospitals. Accessing patient insight in this way need not be complex, yet many of the trusts we reviewed did not have systematic processes for doing so, and all have actions in their action plan to improve in this area.

 Realtime patient feedback and comment must become a normal part of provider organisations’ customer service and reach well beyond the Friends and Family Test.
 Providers should forge strong relationships with local Healthwatch who will be able to help them engage with patients and support their journey to ensuring more comprehensive participation and involvement from patients, carers and the public in their daily business.
 The very best consumer-focused organisations, including some NHS trusts, embrace feedback, concerns and complaints from their customers as a powerful source of information for improvement. Patients and the public should have their complaints welcomed. Transparent reporting of issues, lessons and actions arisng from complaints is an important step that the NHS can take immediately to demonstrate that it has made the necessary shift in mindset.
 Monitor and the NHS Trust Development Authority should consider the support, development and training needed for Non-Executive Directors and Community, Patient and Lay Governors to help them in their role bringing a powerful patient voice to Boards.
 All NHS organisations should seek to harness the leadership potential of patients and members of the public as they fulfil their respective responsibilities whether as providers, commissioners or as part of future inspections by the regulators. Patient and public engagement must be central to those who plan, run and regulate hospitals and each has improvements to make in this respect.

Ambition 4: Patients and clinicians will have confidence in the quality assessments made by the Care Quality Commission, not least because they will have been active participants in inspections.

Based on: The methodology we used for this review has worked well, uncovering both good practice as well as previously undisclosed problems requiring immediate attention and urgent action.

The multidisciplinary nature of the review teams - involving patient and lay representatives, junior doctors, student nurses, senior clinicians and managers - was key to getting under the skin of these organisations. The review teams were not constrained by the limitations of a rigid set of tick box criteria. This allowed both cultural and technical assessments to be made, informed by listening to the views and experiences of staff, and particularly patients and members of the public.

 The new Chief Inspector of Hospitals has agreed to adopt and build on this review methodology as he takes forward the Care Quality Commission’s new inspection regime for hospitals.
 In the new system, the place that data and soft intelligence comes together is in the recently formed network of Quality Surveillance Groups. These must be nurtured and support the Care Quality Commission in identifying areas of greatest risk.
 Provider boards might wish to consider how they themselves could apply aspects of the methodology used for this review to their own organisations to help them in their quest for improved quality.

Ambition 5: No hospital, however big, small or remote, will be an island unto itself. Professional, academic and managerial isolation will be a thing of the past.

Based on: The trusts reviewed tended to be isolated in terms of access to the latest clinical, academic and management thinking. We found many examples of clinical staff not following the latest best practice and being ‘behind the curve’. They - and other trusts not included in this process - need to be helped to develop culture of professional and academic ambition.

 NHS England should ensure that the 14 hospitals covered by this review are incorporated early into the emerging Academic Health Science Networks. We know that the best treatment is delivered by those clinicians who are engaged in research and innovation.
 Providers should actively release staff to support improvement across the wider NHS, including future hospital inspections, peer review and education and training activities, including those of the Royal Colleges. Leading hospitals recognise the benefits this will bring to improving quality in their own organisations. Monitor and the NHS Trust Development Authority should consider how they can facilitate this.

Ambition 6: Nurse staffing levels and skill mix will appropriately reflect the caseload and the severity of illness of the patients they are caring for and be transparently reported by trust boards.

Based on: The review teams found inadequate numbers of nursing staff in a number of ward areas, particularly out of hours - at night and at the weekend. This was compounded by an over-reliance on unregistered support staff and temporary staff.

 As set out in the Compassion in Practice, Directors of Nursing in NHS organisations should use evidence-based tools to determine appropriate staffing levels for all clinical areas on a shift-by-shift basis. Boards should sign off and publish evidence-based staffing levels at least every six months, providing assurance about the impact on quality of care and patient experience.
 The National Quality Board will shortly publish a ‘How to’ guide on getting staffing right for nursing.

Ambition 7: Junior doctors in specialist training will not just be seen as the clinical leaders of tomorrow, but clinical leaders of today. The NHS will join the best organisations in the world by harnessing the energy and creativity of its 50,000 young doctors.

Based on: The contribution of junior doctors and student nurses to the review process was hugely important. They are capable of providing valuable insights, but too many are not being valued or listened to. Junior doctors in particular were receiving inadequate supervision and support, particularly when dealing with complex issues out of hours. They often felt disenfranchised. In some trusts we visited junior doctors are not included in mortality and morbidity meetings because they were considered ‘not adult enough to be involved in the conversations’.

 I strongly advise Medical Directors to consider how they might tap into the latent energy of junior doctors, who move between organisations and are potentially our most powerful agents for change. Equally, I would strongly encourage Directors of Nursing to think about how they can harness the loyalty and innovation of student nurses, who move from ward to ward, so they become ambassadors for their hospital and for promoting innovative nursing practice.
 Junior doctors must routinely participate in trusts’ mortality and morbidity review meetings.

Ambition 8: All NHS organisations will understand the positive impact that happy and engaged staff have on patient outcomes, including mortality rates, and will be making this a key part of their quality improvement strategy.

Based on: From talking to people in the 70 focus groups we conducted as part of the review, it was clear that staff did not feel as engaged as they wanted or needed to be: yet academic research shows that the disposition of the staff has a direct influence on mortality rates.

 All NHS organisations need to be thinking about innovative ways of engaging their staff.
 Addressing this issue is part of the action plans for all of the 14 trusts which provides them with an opportunity to lead the way on this.