One year on since the announcement that a number of the Keogh Mortality Review trusts would be placed in a new ‘special measures’ regime, it has been hailed a success. As the secretary of state acknowledged last month, and the CQC highlights in its report published today, quality in these trusts has improved, staffing numbers increased and trust boards have reinvigorated their focus on creating positive and empowering cultures for staff and patients.

The concept of special measures is new for the NHS, having been borrowed and adapted from the education sector. It therefore seems timely to consider the impact and effectiveness of the regime for trusts, their staff and the patients they serve. 

First and foremost it is important to recognise that although six trusts are remaining in special measures, all 11 should be proud of the progress they have made over the last 12 months. They have been working under a constant, shining media, political and regulatory spotlight, while heading towards a financial cliff edge as NHS finances increasingly tighten. The improvements achieved are a tribute to the leadership and the staff of all involved in the process.

The concept of special measures is new for the NHS, having been borrowed and adapted from the education sector.

A central feature of the regime is ‘buddying’, where trusts are matched with high performing foundation trusts to help deliver the required improvements. While there may be some wrinkles to iron out in terms of selection of buddies, we have been told that, on the whole, the experience of buddying has been positive especially when those on both sides of the relationship (the buddy and the buddied) are committed to learning from each other and have a shared understanding of the local challenges and cost drivers facing the special measures trust. There does seem to be considerable potential in the concept of the peer to peer based learning which buddying offers, which the NHS could learn from more broadly. However, as the HSJ has recently reported, the buddying arrangement does not come without associated costs, and a need for buddies to be recompensed for their time investment.

But the costs of special measures are not confined to buddying. Jeremy Hunt’s speech last week specifically highlighted the increased staff numbers within each trust, which while welcome, will have not come for free. Then there are the costs to the trusts of engaging management consultants to support improvement planning, costs of interim management, the cost of any substantial service changes and not forgetting the opportunity costs associated with the trust’s board focusing on upwards reporting as well as operational delivery.

HSJ analysis has revealed that special measures trusts are predicting a collective deficit of almost £140m this year. Whilst quality comes at a price we do not want trusts progressing well to be caught in a ‘catch 22’ where their financial sustainability is then under increased levels of scrutiny.

Although the responsibility of improving quality ultimately lies with the trust board, no trust is an island

It is important to recognise that it is not just financial costs that trusts need to manage as part of the special measures regime, but also the reputational costs, not least externally with the local media and public, but also internally with the trust’s workforce. Clare Panniker, chief executive of Basildon and Thurrock NHS Foundation Trust - a special measures success story - recently described her trusts’ disappointment at initially being placed in special measures at a time when she felt their turnaround was already underway. The increased difficulty retaining and especially recruiting staff to trusts with this label should not be underestimated.

This highlights an important point and an interesting question – where trusts know they need to make quality improvements and are taking steps to do this, should they be placed within special measures? And how is the board’s autonomy sustained and protected to take difficult decisions and steer the trust into calmer waters while in special measures? There is a huge opportunity cost to dismissing talented board members too swiftly before they have time to make a difference or when issues outside of the trust’s control in the local health economy need collective leadership.

And although the responsibility of improving quality ultimately lies with the trust board, no trust is an island. It is undeniable that every special measures trust is part of a local health economy. Perhaps the regime - the initial stigma of failure and the ultimate credit for improvement - should be shared with local partners, including commissioners.

Embedding the turnaround delivered by special measures requires the wider health economy to collaborate. For instance, the quality summit, held after a CQC inspection, is an ideal place for local stakeholders and commissioners to come together, reflect on the challenges facing the trust and develop a coordinated, joined-up action plan to tackle these together. And it should not stop there. Ongoing joined up working will be key to achieving sustainable improvements in quality.

These are first reflections one year on, not a detailed analysis. But they reflect the conversations we have with our members and partners across the NHS. They highlight areas of opportunity and challenge that should be considered when developing the use of special measures in the future. Overall, the key to its success is ensuring its value for patients in the affected trusts to improve quality and sustainability.