This report can be downloaded in pdf format here.
In recent years, there has been an extraordinary turnover of the occupants of the posts of Chief Executive of the Royal Cornwall Hospitals Trust (RCHT) and Chair of the Trust. With the recently-announced resignation of Kathy Byrne, the Trust is now looking for its sixth Chief Executive (including acting holders of the post) in seven years. And the recent resignation of Jim McKenna as Chair of the Trustees means that the Trust is seeking its fifth Chair in that period.
Ms Byrne herself has emphasized the importance of stable leadership at the Trust, and in October last year, in an interview broadcast on BBC Radio Cornwall, she said: ‘We have finally established a stable leadership team at the Trust’. So it is ironic that only nine months later, after a mere two and a half years in post, she is leaving that team.
Irony aside, the Care Quality Commission (CQC) has made clear the importance that it attaches to stability in management. An inspection team visited Treliske in January 2016, and in its report (published in May 2016) it commented:
There had been significant and continuing instability at board level however the appointment of an experienced chairman in 2015 was having an impact and there was a sense that the leadership team … were working well together.
Sadly, Ms Byrne’s departure is dispelling that optimism.
The effect of changes in leadership is graphically illustrated in another recent report by the CQC, on partnership working to deliver health and social care in Cornwall:
[Talking] with senior system leaders, it was clear that the acknowledged historical differences, together with numerous changes in key leadership roles over several years, had taken their toll on partnership working and relationships. Some leaders were very focused on the ‘long game’, and this included working with an external strategic partner with a view to transformation … Other senior leaders were more rooted in transforming current fragmented systems.
The CQC seems to have uncovered the main reason for the high turnover of RCHT chief executives. Appointees have been expected to take on two very different roles simultaneously: the high-level political/strategic role – the ‘long game’ – of finding a place for RCHT in some kind of integrated health and social care organization within Cornwall’s devolution scheme, and the day-to-day role of getting a large hospital to run smoothly, efficiently, and in a way that conforms to best practice and responds to patients’ needs.
We see this ‘riding two horses’ approach very clearly in the news release that announced the appointment of Lezli Boswell as interim Chief Executive (she was subsequently confirmed in the post) in September 2011:
‘Lezli brings considerable expertise to RCHT, enabling us to maintain our focus on the delivery of our strategic plan and aspiration to be a foundation trust (FT) with all the benefits to patient care that will bring,’ said Royal Cornwall’s chairman Martin Watts.
The potential conflict between patient care and FT aspiration was highlighted, as is well known, in the report by Robert Francis QC on the Mid Staffordshire (Stafford Hospital) public inquiry which he conducted:
There was an unacceptable delay in addressing the issue of shortage of skilled nursing staff. There can be little doubt that the reason for the slow progress in the review, and the slowness of the Board to inject the necessary funds and a sense of real urgency into the process, was the priority given to ensuring that the Trust books were in order for the FT application.
It is no criticism of Ms Byrne to point out that while in post she has been under considerable pressure to devote her time to her strategic role, and to suggest that this may help to account for the fact that the CQC, following an inspection in July 2017, rated the Trust as inadequate overall. Surgery, maternity and gynaecology, end of life and outpatient services were rated as inadequate, although critical care and children and young people’s services were rated as good. The CQC said:
We had serious concerns that systems to assess, monitor, and mitigate risks to patients receiving care and treatment were not operating effectively. We also had concerns that governance systems and processes were not operating effectively.
The CQC served the Trust with a Warning Notice on 29 August 2017. The Notice required it to make significant improvements by 30 November 2017.
The CQC made a further, unannounced inspection of Treliske in January 2018, when it found continuing concerns in surgery, critical care, maternity, and outpatient services. On 6 April 2018 it issued a further Warning Notice requiring the Trust to make further improvements within one week. In particular, it said, there were
serious concerns that systems to assess and deal with risks to patients in maternity and surgery were not operating effectively. Governance systems were not operating effectively in critical care and the fracture clinic … Systems and processes to ensure equipment was of good repair and properly maintained were not operating effectively. Nor were there effective systems for the management of incidents and Never Events, or to comply with the requirements of the duty of candour.
It is hard to resist the conclusion that the CQC’s findings reflected an emphasis at the highest level within RCHT on the high-level political/strategic role as opposed to the day-to-day role of addressing the problems of Treliske hospital identified by the CQC. It may be, too, that those problems required a ‘hands-on’ approach from management rather than an issuing of instructions from on high.
What can be learned from this state of affairs, and what should now be done? Here are three suggestions:
1. The recently resigned Chief Executive and Trust chair should both be asked to submit a report setting out what they have learned in office and offering frank advice to their successor on dealing with the situation they will find. This report should include an honest assessment of the working relationships between the management and senior clinicians. This is surely not unreasonable and should be done as a matter of course as part of the handover process to a new incumbent.
2. Careful thought needs to be given to the job description for the Chief Executive post. It needs to be asked whether it is actually feasible for one person to perform both the strategic ‘long game’ role and the hands-on role identified by the CQC. It may be that the strategic role would be best played by the incoming Chair of the Trust, and the availability of both positions offers an opportunity to bring about such an allocation of responsibilities. So careful thought needs to be given to the job description for the Trust Chair too.
3. The extraordinary turnover of RCHT chief executives in the past seven years does not inspire confidence in the selection processes that have been followed. There should be an obligation on the Trust to show how the members of the selection board have themselves been selected, what their qualifications are, and what criteria they are expected to apply. Like the CQC inspections, these are matters of great public interest to the people of Cornwall, and should be open to the light of day.
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[With thanks to my fellow-members of the committee of West Cornwall HealthWatch for their insightful comments and suggestions.]
31 July 2018
Notes and references. All web sources last accessed on 30 July 2018.
1. Kathy Byrne interviewed by James Churchfield on BBC Radio Cornwall,
5 October 2017
2. Care Quality Commission, Royal Cornwall Hospital, Quality Report,
12 May 2016, p.5
3. Care Quality Commission, Partnership working to deliver health and social care in Cornwall, 4 October 2017, p.7
4. Lezli Boswell starts as interim head of Royal Cornwall Hospitals, Guardian Healthcare, 2 Sept. 2011
5. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive summary, p.45
6. Care Quality Commission, Royal Cornwall Hospital, Quality Report, 5 Oct 2017, p.2
7. Care Quality Commission, Royal Cornwall Hospitals NHS Trust, Quality Report, 5 April 2018, p.5