With special measures attracting increasing attention recently, it’s timely to consider what we have learned from trusts’ experiences so far.
Quality special measures was introduced almost four years ago. It aimed to provide greater accountability and offer support to trusts where there are concerns about the quality of care provided. Special measures was intended to produce quick results; it set a 12-month window for change with the possibility of 6 months’ extension.
Since its introduction 32 trusts have been placed in quality special measures. Although it applies to all types of trusts, it remains the case that hospital trusts are most likely to join the regime.
The graphic below paints a picture of the trends we are starting to see:
What does the data show us?
The first 11 trusts were placed into quality special measures in July 2013, following the Keogh mortality review. All of these trusts have since left special measures, however just five did so in under a year and two of these trusts recently re-entered the regime.
Comparing this to the 21 trusts placed in the regime since then, 13 are still in special measures and eight have exited. None of these trusts left special measures in less than 12 months.
Overall, the 17 trusts that have been through special measures (excluding the two that have recently re-entered) spent an average of 24 months in the regime, double what was planned.
Overall, the 17 trusts that have been through special measures (excluding the two that have recently re-entered) spent an average of 24 months in the regime, double what was planned. This trend looks set to continue as two thirds of trusts who are still in special measures have already been in for over a year.
Since quality special measures was introduced, we have seen financial special measures and the success regime also emerge. This proliferation of special measures regimes has been compared – rather aptly – to waiting for a bus: you wait ages for one and then several come at once. Two are institutionally focused, while one takes a wider health economy approach.
To date, 11 trusts have been placed in financial special measures, with five of these also in quality special measures – all five currently remain in both regimes. There has been limited overlap between the success regime and either financial or quality special measures, so it is not yet apparent how these different regimes interact.
STPs also add another dimension to this complex picture.
This proliferation of special measures regimes has been compared – rather aptly – to waiting for a bus: you wait ages for one and then several come at once.
Some outstanding issues
1. How long is too long?
There are some clear success stories as a result of special measures, where quality has improved significantly within individual organisations. However if the overarching aim of quality special measures was to help resolve quality issues within 12 months, success so far is questionable; prompting us to ask whether the timeframe in which improvements must be made is realistic.
An Institute of Government study, Failing Well, looking at failure regimes across health and other public sectors, stressed there is ‘opportunity to capture and more widely disseminate lessons on turnaround’. This must also include a greater focus on the factors that enabled those organisations with the quickest turnaround to do so.
2. What’s the impact of wider context?
One lesson that has strongly emerged from the literature on the trajectories of schools coming out of education special measures is that context matters. Factors such as servicing an area of high deprivation affect a school’s progress, including how long it spends in special measures. This is certainly something the NHS could learn from.
The special measures regime was arguably designed from an assumption that problems lay within a single organisation. While improvement and pace of change are determined by a whole host of factors, to advance more rapidly on their journey trusts will often be reliant on partners within their health economy. Given the longer periods trusts are spending in special measures, one question to ask is whether future interventions may need to follow a whole-system ethos rather than an institutional focus.
3. How effective is the support?
Another question we might ask is how effective is the external support that trusts receive to make the necessary improvements and does this impact on how quickly trusts exit special measures. Support can come from different sources, including being assigned an improvement director by NHS Improvement. If support is not carefully matched to a trust’s needs or to the causes of failure, there is the risk that this could hinder rather than help progress.
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Just the beginning
Looking at the pace at which trusts exit special measures only tells part of the story; sustaining the momentum of the improvements is essential. While it’s too early to definitively evaluate the trajectory of most trusts post-special measures, the picture appears mixed.
Six trusts have been re-inspected by the CQC following their exit from special measures – most have maintained or improved their ratings, building on foundations laid during special measures.
For trusts now back in special measures, we must consider the longer term challenges they are facing and any common threads running through. While not all trusts’ trajectories are likely to be linear, some of the issues trusts have to tackle, such as staffing, run deeply and can remain prominent concerns even after special measures have ended, or arise out of growing pressures within a challenged local economy. This can ultimately also challenge the extent to which progress can be sustained.
Overall, it is clear that we must learn from trusts’ experience of special measures to date, and build these lessons into the evolution of the regime. This will be all the more vital in the context of developing oversight and accountability processes.
Notes: Four trusts had inspections that did not result in a rating, these are not shown on the chart: Barking, Havering and Redbridge (Dec-13), Barts Health (Jan-14), Worcestershire Acute (Mar-15) and London Ambulance (Jan-17). One further trust was placed in special measures, Heatherwood & Wexham Park, but they were acquired by Frimley Health five months later and are no longer active therefore they have been excluded.
This analysis of special measures has been developed by Deborah Gulliver, senior research analyst and Cristina Sarb, policy advisor - regulation.