Don’t close community hospitals: use them as re-ablement centres

This report can be downloaded in pdf format here.

This report shows how limited and poor-quality information is being used to justify a policy of ‘freeing up’ hospital beds, in effect allowing wards and hospitals to be closed. In Cornwall three community hospitals are currently facing closure. Unfortunately, policy makers seem not to understand that patients stay in hospital not only to recover from their treatment but to go through a process of ‘re-ablement’ so they can regain the skills of daily living and a place in their community. Re-ablement is difficult to achieve in acute hospitals, where patients are more likely to become institutionalized: it calls for specialized re-ablement centres. Local community hospitals should be utilized for this purpose. Staffed by teams of physiotherapists, counsellors and social workers, and providing a base for occupational therapists working in the community, re-ablement centres would take patients who have gone through their acute treatment and would thereby free up beds in acute hospitals.

‘Freeing up hospital beds’: a policy based on inadequate information
NHS England has become very careful lately to avoid suggesting that it is seeking closures of hospital beds and, by implication, hospitals. But we currently see numerous references to ‘freeing up’ hospital beds, as in the recently published NHS Long Term Plan.[1]

In Cornwall we keep being told: ‘Older people can lose 5% of their muscle strength per day of treatment in a hospital bed.’[2] Interestingly, we are never told how much exercise, if any, those ‘older people’ were given. Nor are we told how much muscle strength people lose if confined to bed in their own home. Without this information, that figure of 5% is utterly worthless as a basis for policy making. And the cost of having physiotherapists spending time driving around (with limited equipment) instead of treating patients throughout the day is another factor that policy makers show no sign of taking into account.

We are also told that ‘Around 60 people each day are staying in an acute hospital bed in Cornwall and don’t need to be there’, and that ‘35% of community hospital bed days are being used by people who are fit to leave’. We aren’t told, though, who is making these judgments and what they are taking for granted about a patient’s ability to cope after leaving.

It seems all too likely that these judgments are being made by hospital consultants who consider that there is nothing more that they can do for the patient and are not taking any account of the patient’s housing opportunities or indeed of their need for ‘re-ablement’.

At the present time occupational therapists working in the community are noticing that people are being discharged from hospital despite being very unwell. Evidently, under the pressure to free up beds, too little attention is being paid to the capabilities of patients who are in line for discharge.

The pressures
In NHS hospitals today there is a chronic shortage of funding and of staff. Many staff are overworked, they go home exhausted, and their morale is understandably low. Most of them know what patients need and are frustrated because they don’t have time to provide it. Medical procedures, administering medication and changing dressings have to take priority over encouraging and supporting patients. And pressure of time limits the attention that can be given to the particular needs of an individual.

In some wards, especially geriatric wards, patients who struggle to feed themselves become undernourished because ward staff don’t have time to feed them. Patients who need to be helped to drink become dehydrated. Patients who need but don’t get help with toileting, either using a bedpan or going to the bathroom, may soil themselves and be left in that state for some time.

Imprisoned in hospital
Hospital in-patients, just like the inmates of prisons, are confined. Indeed, they may be confined more tightly, if they are in a bed from which they can’t escape. The lives of both patients and prisoners are governed by a discipline, decisions and a daily timetable over which they have no control. If there are disruptive fellow-inmates in close proximity, patients suffer from a lack of privacy and access to their possessions, and very probably from sleep deprivation too.

Subjected to these conditions, many elderly patients become resigned to their fate, especially if they have been living on their own and have had an accident, been taken to hospital, and then not only found themselves confined in a hospital bed but faced with the fact that they will never see their home again. Many give up. Their mental health, like their physical health, gets worse and worse. They are conditioned to become dependent. They become, in a word, institutionalized.

Reducing reliance on bed-based care
We are currently being told in Cornwall that ‘reducing reliance on bed-based care’ and instead having people ‘supported at home and kept as independent as possible, whenever possible … provides a better experience of care for individuals’. The subtext here is of course that with less reliance on (hospital) bed-based care there will be less need for hospital beds.

What this argument leaves out is any comprehension of the last of the four processes that constitute a patient’s ‘trajectory’ through a hospital: (1) admission and observation; (2) treatment; (3) recovery from treatment; and (4) re-ablement.

Processes 1-3 need no explanation. But note that preparing patients to leave hospital requires more than just recovery from treatment. They have to be equipped to regain their autonomy (the ability to take decisions for themselves), their self-confidence and the physical and mental skills they need for daily living, so they move from a passive state to an active one. This fourth process is known as ‘re-ablement’.[3]

Shockingly, we are told that ‘older people admitted to hospital spend a significant amount of time not being physically active (83-95%)’. What this tells us is that far too little is being done to prepare patients for leaving hospital. Far too little attention is being paid by hospital managers to re-ablement, and consequently far too little by way of resources is being devoted to it.

The re-ablement model and the role of the physiotherapist
Who is best placed to help patients and guide them through the re-ablement process? Ideally it will be someone who can form an ‘alliance’ with the patient. Historically this has never formed part of a nurse’s role. Nurses care for patients during their recovery, and good ones have excellent ‘people skills’, but they are not taught and trained to work with patients, to form an alliance with them.

However, there is one professional group who are taught that it is their responsibility to work with patients in the re-ablement process: they are the hospital’s physiotherapists, members of an ‘allied health profession’. It is their responsibility to ‘mobilize’ patients and restore their fitness.

It is time to rethink the role of physiotherapists. Although they are conventionally viewed as playing an ancillary role in acute hospitals, they don’t just do exercises with people. They take a 3-year training course, during which they learn anatomy (nearly to the same level as doctors), as well as physiology and pathology. They are vital members of teams which carry out transplants, and they work in intensive care and medical wards.

Physiotherapists are equipped to play a key role in the re-ablement process. It is they more than any other professionals who can assist patients to regain their autonomy, self-confidence and physical and mental skills, and leave hospital to resume their place in their community.

The skills of physiotherapists put them in an excellent position to add ‘personal trainer’ to their portfolio of skills. They know very well that working with patients involves treating them as allies. They appreciate the importance of helping patients to set goals and providing feedback on their progress. With continuing professional development, as the recently-published NHS Long-Term Plan says, they would also be well placed to help patients suffering from anxiety and depression.[4]

A re-ablement service needs to be properly staffed and financed. If it is not, patients will be competing for resources: inevitably younger patients, with jobs and family responsibilities, will be given priority. Older people will be at the back of the queue: they won’t get enough exercise, they will continue to lose muscle strength that they will never regain, and they will stay in hospital longer than necessary. But if enough resources are devoted to re-ablement, the number of people staying in a hospital bed in Cornwall who ‘don’t need to be there’ will certainly be reduced.

Re-ablement centres: a use for community hospitals
Hospitals are commonly known by the services they provide. For example, Cornwall’s main hospital at Treliske, near Truro, is described as the provider of acute care services for the county. Cornwall also has a number of so-called ‘community hospitals’, three of which are currently closed to in-patients and at risk of being closed completely and the buildings and land sold off.

Taking a ‘process view’ of hospital provision in Cornwall, one thing stands out. To date, consultants and managers have not shown much if any interest in the re-ablement process. Consultants appear to be no longer interested in patients once recovery from treatment is under way, while managers seem most sensitive to beds being ‘blocked’ (‘delayed transfers of care’). It would suit both groups to have patients moved out of the acute care hospitals after they have received treatment, and if re-ablement centres can be established at the community hospitals, these are the obvious places to move patients to. They would also be closer to home.

Recommendations
Cornwall’s Clinical Commissioning Group should commission ‘physiotherapy-plus’ re-ablement centres for patients, to be based in community hospitals that might otherwise be sold off. Providers would be paid not to supply ‘warehouse space’ to accommodate patients while they regain their autonomy after their incarceration in the acute hospital but to employ teams of physiotherapists, counsellors and social workers in properly-adapted accommodation to create a stimulating mental and physical environment for them.

These centres should also serve as bases for occupational therapists who provide a service to people in their own homes, so there can be continuity of care for former in-patients. And the NHS should affirm the status of therapists as being central, not peripheral, to the process of helping patients to leave care fit and well and raring to go. Finally, policy makers should be reminded that if more resources are provided for re-ablement, this will undoubtedly reduce the number of people staying in an acute hospital bed in Cornwall who ‘don’t need to be there’.


Notes and references (Websites last visited on 22 January 2019)

  1. The NHS Long Term Plan, January 2019, pp.7, 14, 18, 21
    www.longtermplan.nhs.uk
  2. These figures have been supplied in the course of a consultation currently taking place in West Cornwall. See also Peter Levin, ‘Community hospitals under threat: Are decisions being taken on scrappy information and limited understanding?’, 7 August 2017
    http://spr4cornwall.net/wp-content/uploads/Community-hospitals-under-threat.pdf
  3. ‘Re-ablement: The active process of regaining skills, confidence and independence after a traumatic or ischaemic injury.’
    https://medical-dictionary.thefreedictionary.com/re-ablement
    See also Karen Johnson, Recognizing and treating depression in hospital patients’, 24 October 2017
    https://blog.medstarwashington.org/2017/10/24/recognizing-and-treating-depression-in-hospital-patients/
  4. As Note 1, p.11

Further reading
Peter Levin, ‘Five kinds of nonsense keeping a community hospital closed’, 4 October 2017
http://spr4cornwall.net/five-kinds-of-nonsense-keeping-a-community-hospital-closed/

 

We don’t want a prima donna to head the hospitals trust

On January 15th interviews will be held for the post of Chief Executive of the Royal Cornwall Hospitals NHS Trust.

The Trust is now looking for its seventh Chief Executive (including acting CEs) in eight years: interviewing panels for this post evidently do not have a great track record!

Who will be on this year’s interviewing panel? One member will obviously be the Acting Chair of the Trust; another will certainly be from NHS Improvement, the regulating body for NHS trusts. A third is likely to be a Chair or Chief Executive from another Trust. In these jobs not one of them is likely to be having daily contact with wards or clinics, of course.

What sort of person will these high-ups be looking for? In the past the emphasis has been on delivering the Trust’s strategic plan and gaining Foundation Trust status. When in 2015 Kathy Byrne was parachuted in from Australia, it was to play a ‘system leadership’ role. In the current job description the Acting Chair of the Trust writes that they are seeking a ‘strong and charismatic’ Chief Executive: a ‘brilliant’ leader who can provide ‘outstanding and inspirational leadership’ is required.

All this seems a world away from reality. The reality is that the Trust is an organization with deep-seated problems. The 2017 Staff Survey asked staff whether they thought the Trust’s procedures for reporting near misses, errors and incidents were ‘fair and effective’, and whether they felt ‘confidence and security’ when reporting unsafe clinical practice: on both counts the Trust came in the bottom 20 per cent in their category of trusts. And more workers than in comparable trusts said they had experienced harassment, bullying or abuse from other staff.

There’s more: a recent study of events leading up to the tragic death of six-year-old Coco Bradford in 2017 exposed a shambles in the organization for which no-one has been brought to account.

One thing is crystal clear. What the Trust does not need at its head is a prima donna, a chief executive whose charisma and brilliance will inevitably attract a coterie of self-promoting sycophants. It needs someone who can manage the organization without bullying or harassing people, who listens to staff and patients rather than just giving orders, who can weld the organization into a team, in which communications run bottom-up as well as top-down. In a nutshell, we need someone who can give genuine meaning to the Trust’s motto: ‘one and all, we care’.

The Royal Cornwall Hospitals NHS Trust is headhunting. Applicants should ask questions about its culture.

This report can be downloaded in pdf format here.

The Acting Chair of the Royal Cornwall Hospitals NHS Trust says it needs ‘culture change’ but there are very different views of what that means and how to bring it about. The National Guardian’s Office has found deeply entrenched problems which the Trust is in danger of perpetuating.

Towards the end of 2018 the Royal Cornwall Hospitals NHS Trust began recruiting for a number of senior posts: a Chief Executive, along with Clinical Directors, Heads of Nursing etc, and General Managers, who are to head – as triumvirates – seven new ‘care groups’.[1,2,3,4]

The job descriptions and person requirements for the three categories of care group heads all refer to the importance of ‘culture’ and encouraging teamworking and good working relationships. This looks like an imaginative and positive response to a report recently published by the National Guardian’s Office (NGO) following a review of the Trust: this found that ‘workers described a culture that was highly unsupportive’[5] and that ‘relations between staff in several parts of the Trust were poor and were characterized by a grievance culture’.[6]

One worker told us that staff where they worked ‘got into trouble’ for raising concerns. Another, working in a different service, said: ‘If you do speak up middle management will block you.’ Two workers from one service commented: ‘Nobody has acknowledged our difficulty or concerns, and we won’t speak up again.[7]

Several staff from different services also commented that there was a culture of managers telling workers not to raise and record issues using the Trust’s electronic incident reporting system. These staff members said they believed this culture created risks to patient safety.[8]

A highly unsupportive culture like this is clearly detrimental to patients. An emphasis on teamworking, which was exposed as sadly lacking in a recent case that led to the death of a six-year-old child,[9] would be a way of developing a supportive culture and – importantly – foster good communication among staff.

The job description for the new Chief Executive is a strikingly different document. The Acting Chair of the Trust has provided an introduction in which she writes ‘We have a significant culture change to make’, but does not spell out what she means by that, and says her colleagues (i.e. the staff) ‘deserve a strong and charismatic Chief Executive to lead them on their journey’. We also read in the document that the appointee is expected to show ‘outstanding and inspirational leadership’, and that the role requires ‘a brilliant and capable leader’.[10]

One would not want to deny that capability and flair are valuable assets in a leader, but the dazzle of brilliance and charisma should not distract us from the fact that there is work to be done. What is the Chief Executive expected to do?

When we look at the job description for the Chief Executive we find no fewer than 54 bullet-pointed tasks. Several of them begin with ‘ensure’ or ‘ensuring’.

So an applicant for the post needs to ask, for example: How, exactly, will I be able to ensure ‘that the quality of patient care is central to the functioning of the Trust’?

We also see from the job description that he or she is to ‘champion a culture of innovation, continuous improvement and trust’ and ‘champion an open and inclusive culture and management style that is receptive to staff involvement, being effective in working relationships and communications with colleagues so they feel motivated, developed, supported and respective (sic)’. All well and good, but the applicant needs to ask: How, exactly, will I be able to do this ‘championing’?

Which raises the question: What resources will be available to the successful applicant for the purposes of ensuring and championing?

On this the Chief Executive’s job description is silent, unfortunately.

However, it does provide a rudimentary organization chart. This shows a hierarchy, with the Chief Executive perched on top of a row of six directors, one of whom is the Chief Operating Officer, who will be similarly perched atop the seven care groups. Anyone applying for the Chief Executive position should ask whether they would be dependent on the Chief Operating Officer for information from within a care group. That person may well have an incentive not to pass upwards information about a problematic situation in a care group if, for example, that would reveal negligence on his or her part. Hierarchies can be hugely dysfunctional for this reason.

The NGO review mentioned above found several instances of the Trust failing to act to address issues raised when staff spoke up. Their report said these were in breach of the Trust’s speaking up policy that states that the trust is committed to ‘listening to our staff, learning lessons and improving patient care’.[11] (Italics in original)

Workers are the eyes and ears of an organisation and are often first to identify actual or latent issues that could impact on an organisation’s ability to deliver its objectives.[12]

The instances described in the NGO report highlight the need for the Trust to ensure that it responds appropriately to its workers who speak up.

The Trust’s policy on speaking up states: ‘In accordance with our duty of candour, our senior leaders and entire board are committed to an open and honest culture. We will look into what you say and you will always have access to the support you need.’[13]

How can this obligation be fulfilled? How can the Chief Executive connect himself or herself with the eyes and ears of the Trust’s workers? Will they, for example, be able to set up their own unit of open-minded ‘roving inspectors’ who are not bound by the restrictions of hierarchy but free to talk to any Trust employee who is involved in patient care?

What the Chief Executive does receive at present is formal reports. At the foot of Page 4 of the Chief Executive Recruitment Information Pack, you will find a link to ‘the Trust Improvement Programme’, a page on the Trust’s website.[14] At the foot of that page is a further link to ‘Trust Improvement Plan – October 2018 update’. That update (the latest) consists of a four-page report to the Trust Board entitled Quality Improvement Programme update.[15] On Page 3 of that report is an Executive Summary, where we can see half a dozen points under the heading ‘Culture and Leadership’.

While these points may go some way towards building a more cohesive workforce – e.g. ‘Increasing local activity seen throughout social media on informal events for staff to come together to build better working relationships which will improve patient care’ – they fall a long way short of exploring and learning from case-studies of actual patient care and of staff speaking up. They also leave unanswered the question of whether workers who carry out ‘hotel’ functions that have been outsourced to Mitie are treated as ‘staff’. So here are more matters which you may wish to explore if you are called for interview.

Importantly, the NGO report noted that there may be cultural issues specific to Cornwall:

Staff comments often referred to a historic poor speaking-up culture across the trust. One senior leader told us: ‘There’s a long and dark history to this Trust, and to Cornwall generally. Getting through to people is labour intensive. Getting through to them to believe that they will really be listened to and taken seriously has been the most difficult of anywhere I have seen.’[16]

Workers highlighted the geographical location of the Trust as a factor in poor staff relations, stating that because of the Trust’s relative isolation staff often stayed in their roles for many years, and where they remained so did the poor relations between them. One senior leader commented: ‘Many [staff] have a long length of service … Their views become entrenched.’[17]

If you are applying for the Chief Executive position you may wish to think about these comments in advance of being interviewed, and also ask the interviewing board for their views on them.

My own conclusions from this brief survey are two-fold and they are stark. First, the culture of the Trust badly needs a shake-up. It is ossified and it needs a revolution. Second, the notion that what the Trust needs is a brilliant, charismatic leader sitting at the top of a hierarchy is utterly misconceived: there is no way in which this can produce beneficial cultural change.

What is needed is a combination of old hands and young minds: old hands to keep the ship steady, and fresh young minds to ask questions, talk to everyone irrespective of their official position, and bring the energy of startup enterprises to the 70-year-old NHS.

And who knows: perhaps we can look forward to the appearance of the Royal Cornwall Hospitals Teamwork Manual. That really would be something!


Notes and references [All websites last accessed 31.12.2018]

  1. Royal Cornwall Hospitals NHS Trust, Chief Executive Recruitment Information Pack, December 2018
    http://spr4cornwall.net/wp-content/uploads/CEO-Recruitment-Information-Pack-RCHT-Dec-2018.pdf
  2. Royal Cornwall Hospitals NHS Trust, Clinical Director, November 2018
    http://spr4cornwall.net/wp-content/uploads/Job-description-RCHT-Clinical-Director-Nov-2018.pdf
  3. Royal Cornwall Hospitals NHS Trust, Head of Nursing/Allied Health Professionals, December 2018
    http://spr4cornwall.net/wp-content/uploads/Job_description-RCHT-Head-of-Nursing_AHP-Dec-2018.pdf
  4. Royal Cornwall Hospitals NHS Trust, Care Group General Manager, December 2018
    http://spr4cornwall.net/wp-content/uploads/Job_description-RCHT-Care-Group-General-Manager-Dec-2018.pdf
  5. National Guardian’s Office (NGO), A Review by the National Guardian of speaking up in an NHS Trust, December 2018, p.12
    https://www.cqc.org.uk/sites/default/files/20181219%20-%20Royal%20Cornwall%20NHS%20Trust%20-%20A%20review%20of%20the%20handling%20of%20speaking%20up%20cases%20.pdf
    OR http://spr4cornwall.net/wp-content/uploads/NGO-20181219-RCHT-Review-by-National-Guardian-of-speaking-up-in-an-NHS-trust.pdf
  6. NGO (as Note 5), p.4
  7. NGO (as Note 5), p.12
  8. NGO (as Note 5), p.12
  9. Peter Levin, How a lack of teamwork at the Royal Cornwall Hospital contributed to the death of a child with autism, 19 December 2018
    http://spr4cornwall.net/wp-content/uploads/Lack-of-teamwork-at-the-Royal-Cornwall-Hospital.pdf
  10. Royal Cornwall Hospitals NHS Trust (as 1)
  11. NGO (as Note 5), p.19
  12. NGO (as Note 5), p.19
  13. NGO (as Note 5), p.12
  14. Royal Cornwall Hospitals NHS Trust, Trust Improvement Programme,
    https://www.royalcornwall.nhs.uk/our-organisation/about/trust-improvement-programme/
  15. Royal Cornwall Hospitals NHS Trust, Quality Improvement Programme update,
    https://doclibrary-rcht.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/ChiefExecutive/TrustBoard/Minutes/1819/201810/App09TrustQualityImprovementProgrammeUpdate.pdf
    OR http://spr4cornwall.net/wp-content/uploads/RCHT-Quality-Improvement-Programme-update-4.10.2018.pdf
  16. NGO (as Note 5), p.12
  17. NGO (as Note 5), p.11