Mark Brandreth

Mark has been the chief executive at Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust. since April 2016. He joined from the Countess of Chester NHS Foundation Trust where he was deputy chief executive and director of operations and planning. Mark has also worked in Wales and was invited to work for a period in a national role at the Department of Health. Mark has a particular interest in improving services for patients and improving organisational culture and change.

Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust is a specialist orthopaedic hospital. We carry out more hip and knee replacements than any other hospital in England. We also are one of the biggest centres for hip and knee revisions for patients that are having a second replacement because of infection, or for other reasons. We manage the spinal cord injury unit for the whole region, are one of the national bone cancer units and provide specialist paediatric orthopaedic care. There are currently some significant issues with the commissioning of specialised services nationally. It's an area where we have all faced challenges in getting the right approach. I appreciate a lot of thinking is underway at NHS England and with colleagues across the sector now to make improvements and there are some changes coming.

There’s been a lot of short-termism in the approach in recent times – a lot of these services are propped up on out-of-job plan working because the demand and capacity available don't match, and there's a lack of realistic long-term planning. For instance, we are about 50 spinal cord injury beds missing in the country. Demand is going up and up and we’re nine beds short for our region. These are real and serious issues affecting patients, staff and trust viability.

However, now providers are taking on the challenge themselves and working together. The chief executives of all the spinal cord injury centres across the country recently got together to explore what we think the issues facing the service are and what we can do together. I see that as a real positive and a chance to bring together those with the most expertise and insight into these specialised services to see what we can do to forge a more effective delivery model.

Integrated care systems

In the development of ICSs, the role of services bigger than the population served by the ICS has not been thought about well. Trying to work out how those services get a voice and get considered is an issue. An ICS is a series of more mature relationships, where issues and risks are being shared across the system. Most district general hospitals have moved off payment by results, and are moving on to versions of risk sharing contracts – block contracts, but where some of the risk is covered.

I’m a massive supporter of the ICS process. I think it’s completely the right thing to do.

   

Locally, we've got a risk-share contract for musculoskeletal conditions with our commissioners. It's not perfect, but it gives you a sense of the direction we're moving in. It's in our interest and theirs to have an economically viable system that can meet demand – so it's in both our interests to prevent people getting bad hips, knees and backs, rather than just looking after them when they’re sick. We're part of that locally, but that hasn't happened in specialised services because there's not the same level of maturity, trust or relationship in the system. It's too distant, it's too remote.

I'm a massive supporter of the ICS process. I think it's completely the right thing to do, but if the paradigm we're moving to is 'competition is dead and it's all about collaboration', we need a much stronger collaborative network between providers of specialised services and commissioners of specialised services.

Maintaining and improving care quality

From a surgical point of view, the outcome and experience data all show that you want to be operated on by a surgeon that's done 50 of those this year, not two. The outcomes and the value for those patients is way better when there's a combination of a surgeon doing enough procedures and the centre doing enough. We know district general hospitals (DGHs) have to concentrate more and more on the frail elderly. As their skill base changes, it's very difficult to do anything that is low volume/high acuity orthopaedic surgery in a DGH because they're not doing enough of it. In a way this should force more reconfiguration and more surgical networks, but we all know how much that's been resisted.

As a sector, the specialist trusts have got the patient experience right through the staff experience. That’s because the organisations tend to be smaller and focused. From a patient's point of view, they are experiencing world-class care, usually consultant delivered.

There are issues about what happens beyond discharge. My consultants get very anxious about the follow-up care that the patients they're seeing will get once they are back in their communities. The consequence is that we hang onto patients longer than we should need to, and we also bring patients back to a specialist centre when they could be supported with appropriate follow on, or step down care locally.

The way we are responding to the drive to provide more care in community settings is working in partnership, we are leading the development of new musculoskeletal pathways across the whole county. It doesn't mean every physio and occupational therapist will work for us, but what it means is that we'll ensure a gold standard quality of services right across the piece and we'll do that with our colleagues in the community hospitals and local authorities. That's our contribution to the system work – to take what we're good at and try to enshrine it across all the providers.

We also provide the orthopaedic trauma service at the local DGH. We support our partners – we're very much part of the system. We are a small hospital so we're dependent on our neighbours for a range of medical services to support our infrastructure too – our biomedical science service and our blood service and so on is provided by the hospital down the road. Anyone running effective healthcare now cannot possibly be an island – it's impossible to do it.

Anyone running effective healthcare now cannot possibly be an island – it’s impossible to do it.

   

Capital and workforce challenges

Access to capital is a problem and we are less efficient because of a lack of access to that funding. Do we need a national approach to capital? Yes, definitely. We opened a new £10m theatre three years ago and it was completely vital to our continued success. We now don’t have the prospect of doing anything like that again.

If in two years' time I could get access to £20m capital, I could save £10m per year recurrently through efficiency and increased work. We've got outdated kit – we need a new EPR [electronic patient record] for example.
We also need to make updates to physical buildings, and to diagnostics kit – the kit is getting more expensive because it's better quality, and the quality of the images makes us safer. The element that is really worrying me is investment. That's where I think we're particularly starved at the moment.

About 30% of our work is done on an out-of-job plan basis, above what’s in our contracts of employment. The pensions issue has been totally devastating – spinal surgeons are not ten-a-penny and to do the really complex work often involves two surgeons operating together over a ten-hour period. It's not something where you can suddenly increase capacity.

That’s our contribution to the system work – to take what we’re good at and try to enshrine it across all the providers.

   

These are senior experienced consultants that we need to look after, and get them to train and develop others through the ranks. It takes a good surgeon seven to ten years to get up to this standard – you can't fast track that. We've invested in some really good young spinal surgeons but I have to take a long-term view. As a specialist centre, we are an attractive employer so I am still able to recruit. I don't have a big problem recruiting doctors but the trust struggles to attract and retain scrub and ward nurses, although if you look at us compared with many places I realise as a specialist trust, on balance, we have many strengths. I hope that the staff experience we offer means that we can become fully established for nurses in the next period. That would be a real achievement and something we intend to deliver.