In October 2015, Sherwood Forest Hospitals NHS Foundation Trust received a Care Quality Commission (CQC) rating of ‘Inadequate’ and went into Special Measures. This year, CQC rated King’s Mill Hospital as ‘Outstanding’, making it the first hospital to go from Inadequate to Outstanding, and the trust overall was rated ‘Good’ for the second time in a row. The chief executive, Richard Mitchell, shares his insights on how the trust made sustained changes over the last five years to dramatically improve their culture and quality of care.
The story certainly begins before I joined the trust as its tenth chief executive in six years. Peter Herring joined as interim chief executive in November 2015 and in February 2016 it was announced Sherwood would enter into a strategic partnership with Nottingham University Hospitals NHS Trust (NUH) with Peter Homa the joint chief executive of the two trusts. In November 2016, CQC upgraded Sherwood to Requires Improvement and it was decided the two trusts would continue to work closely together, however a full merger would not be required. The first stage in the Sherwood improvement was achieved through stable leadership provided by the two Peters and Andy Haynes (SFHFT medical director between 2014 and 2019), support from NUH, the benefit of a buddying arrangement with Royal United Hospitals Bath NHS Foundation Trust, close working with colleagues in commissioning and most importantly a growing belief from the team at Sherwood that they themselves could deliver the change.
A recipe for improvement
In June 2017 I joined Sherwood. Despite the recent improvements, the reputation of the trust remained poor, the culture was fragile and there were many interim managers and locum clinicians. As a first time chief executive I recognised my appointment was a risk to Sherwood, my colleagues and our patients, and equally the history of the trust since 2011, suggested a lengthy and successful tenure as chief executive was far from guaranteed.
Between being appointed and starting at Sherwood, I contacted many experienced chief executives and other senior leaders who had delivered improvement and who had a reputation for delivering in the “right way” and I asked them for their advice. I will always be grateful for the time they spent with me and the support they gave me. Their advice was invaluable and following conversations with colleagues at Sherwood, we agreed to initially focus on four areas to improve.
The logic for focusing on these four key areas is simple; people who feel consistently well supported, whatever their profession or industry will do a good job. We believe kindness, compassion, inclusion and a genuine interest in others makes a difference. When you have a reputation for treating people this way, and it takes time to build this, it is easier to recruit and retain the best possible people.
Recruiting and retaining the best possible people
There were many excellent colleagues at Sherwood in 2017, but we needed to further strengthen the team with new people joining and honest conversations with some people already working at the trust. We were very clear about the qualities that were accepted at Sherwood and they became characteristics for recruitment and for career progression.
Delivering the level of care we would want our families to receive
When you have a stable leadership team, colleagues who feel listened to and are energised by the new people joining the Trust, you then have the ability to improve the level of care the trust provides. Poor care is not provided by bad people. We believe poor care is, in general, a result of colleagues not feeling listened to and people working in cultures which accept bullying or variable leadership. The first question to ask of organisations that do not deliver consistently high quality care is, “what is the culture like”?
The fourth and final point in the plan was improving the way we communicate. We recognised we needed to communicate more effectively and our communication would take different forms. We write a personal weekly blog often focusing on how we are feeling and personal vulnerabilities (this week is blog #157), we have much greater executive visibility now, including transparency of where the executive team have been over the last month (an idea borrowed from St George’s University Hospitals NHS Foundation Trust) and we recognise and communicate when we have not done something well (such as changes to car parking) or had a particularly challenging week. Social media is a powerful platform but it needs to be used responsibly. We think it is dangerous and disingenuous to only communicate the things that are going well and we regularly communicate the many things we have not managed effectively. In the week we received an Outstanding rating at King’s Mill Hospital, we also communicated and recognised the many things that had not gone well that week.
Strengthening relationships locally
In late 2018, we had seen sustained improvements at Sherwood and we started to focus on strengthening our relationship with health and social care partners, in particular through the Mid Nottinghamshire Integrated Care Partnership, one of the three ICPs in the Nottinghamshire Integrated Care System. Sherwood leads the Mid Nottinghamshire ICP and our relationship with local partners has improved dramatically over the last couple of years. We have appointed a joint director of people with Nottinghamshire Healthcare NHS Foundation Trust and we have a local GP within our senior leadership group at Sherwood.
In April 2019 we launched our new strategy at Sherwood called “Healthier Communities, Outstanding Care”. It came from over 700 conversations and listening events with different stakeholders and it provides the framework for how we have moved beyond just providing hospital based healthcare, to working more closely with health and local authority partners. The ideas for the strategy came from learning from Northamptonshire Healthcare NHS Foundation Trust, East London NHS Foundation Trust and Wigan Council. None of the three are acute NHS trusts and this indicates our interest in learning from the best.
The improvement at Sherwood began five years ago with the CQC Inadequate rating and there are many things we are proud of. We are particularly proud patients and colleagues at Sherwood and across the system now say it feels like a completely different place to work and receive care. We have measured improvement in a number of ways.
Every year for the last four years our scores in the NHS staff survey have improved and we now have the ninth best staff engagement scores for an NHS acute trust. No trust has improved their staff engagement, as measured by the NHS staff survey, as much as us in the last three years, but as our rating suggests there are eight acute trusts better at staff engagement than us and circa 1/10 colleagues at Sherwood would not promote Sherwood as a good place to work. We recognise we have much more to do here to have a truly inclusive culture.
CQC returned this year and rated King’s Mill Hospital as Outstanding overall, identifying it as the first hospital to go from Inadequate to Outstanding. We were particularly proud of this because over 90% of our services are based at King’s Mill. Our other two sites Newark Hospital and Mansfield Community Hospital are rated Good and all 15 of our services are rated Good for safety. We have been buddying and learning from Queen Elizabeth Hospitals King’s Lynn NHS Trust for over a year now and we have delivered our year-end financial position for three years despite spending 16.5% of our turnover servicing our PFI deal.
The last couple of months have been tough but we are proud of our approach to COVID-19. We began fit testing colleagues in January, we delivered a four-fold increase in critical care capacity, we have been providing mutual aid to a range of partners across Mid Notts and early on we focused on well-being and psychological support for colleagues. We are all tired but colleagues report they have felt supported, safe and listened to. We believe we have managed the last couple of months well because of the culture we had in this trust before COVID-19.
Looking to the future
Next year will be even more difficult but we are confident we will continue to improve. The four areas of focus for the next 12 months are learning to live with COVID-19 in our hospitals and communities, further improving our culture, improving the patient experience at a time when elective waiting times have slipped and working with partners across Mid Notts to deliver change wider than hospital based care.
Whilst we have improved dramatically over the last couple of years, not everything has gone to plan and we are aware there are many organisations that are better places to work or receive care than us. If I think about the advice I received three years ago and the way we have gone about improvement, the thing I think is most important is kindness, inclusion and compassionate leadership. You cannot change the culture in your organisation overnight and there is always room for improvement. We are all human and the times when we have struggled over the last three years are when we have not treated people consistently in line with our values or when I have not communicated the rationale for change as effectively as I could have done.
We are proud of the improvements at Sherwood and I would be the first to acknowledge there are many things we do not get right. We have lots more to do and I am confident the team at Sherwood are up to the challenge.