Warrington and Halton Hospitals

Chairman's blog - Steve McGuirk

My blog aims to offer an insight into the running of our hospital, and the issues that myself as chairman and my non-executive colleagues help the trust develop and decide upon.

I joined the trust as chair at the beginning of April 2015, after retiring as county fire officer and chief executive for Greater Manchester.

I welcome your comments on the blog and questions – please note that these are moderated before we publish them. You can also follow me on Twitter at @WHHFTChair

17th December 2015

' The last few weeks have really put us under enormous pressure for a number of reasons - but the response or the staff has been amazing.

We have been experiencing demand at records levels ( very much like the rest of the country) - so Warrington Hospital is really 'bursting' at the seams.

Just the other day I went round the the wards and departments to hand out chocolates for Christmas, and to say thank you to colleagues for their hard work. And I think it's only when you walk round a hospital in this way that the statistics and targets and 'metrics' we spend so much time analysing at the Board really come to life. I think it's truly important for people like me to keep grounding what this means for people in terms of the operational reality of trying to deal with massive challenges and huge demand.

In the last few months we have seen dramatic improvements in meeting many of our targets - for example the four hour waiting time. We are not at the 95% yet - and we are not complacent - but we have made a lot of change and are getting much closer to it ( although we could also have an interesting debate about the value of the target). Nevertheless, against the backdrop of the impact of an ageing population, social care cuts and demand this is a real achievement.

But, in amongst this - as if it wasn't enough - we also went live with the biggest technology project we have ever attempted, an electronic patient record system. ( I have mentioned this already but it's worth putting in context a little more).

Going live with this now was not something we would have done in an ideal world. But we are between a rock and a hard place. If we don't introduce technology like this, we will continue with systems that are hugely bureaucratic, very difficult to maintain accurately and up to date ( all paper based) and impossible to help us change and improve the 'patient flows' ( the way we manage our beds and the occupancy of those beds).

Of course there have been difficulties ( and again I do thank people for their forbearance once more) but overall the introduction has gone as well as anywhere before ( and better than most).

As if that wasn't enough we have had the little matter of the junior doctors industrial relations issue to plan for and deal with (the first strike was cancelled just the day before and so still had an impact on us).

And as if that wasn't enough we are still grappling with making cuts to reduce a £14.2 million deficit ( we had our bi-monthly scrutiny meeting with our regulator Monitor last week); and we are still delivering an extensive action plan to improve against our Care Quality Commission (CQC) report from earlier in the year.

This is just a huge agenda - and hopefully gives some sense of what life is like for a District General Hospital just about now. Tougher and more demanding than ever before - and with even bigger change on the horizon.

It's little surprise that people in the NHS feel a little worn down and frustrated?

But in my few months in the NHS I have been amazed and inspired by so many people - and so despite the pressure, it's still the case that there is deeply held belief and passion for patient care and safety and I am very proud of how we are maintaining these standards.

So I would publicly like to thank each and every one of our people , and wish all our staff, our Trust members and of coy are our pairings best wishes for Christmas - remembering that we are a hospital and open for business 24/7 throughout the Christmas period. Although, it would be really helpful if people only call upon our services when they really do need them.

Merry Christmas


Sharing an article of interest

8th November 2015

Someone sent me this the other day - Christopher Smallwood Guardian article - and I thought I would share as I think it captures very well many of the issues frustrating chairs of boards - and many in the NHS - and also the artificial debate that is taking place about money.

Of course, the rest of the public sector faces enormous cuts - in fairness, actually, even bigger cuts when viewed in a pure mathematical way.

In my last five years as a CEO in the public sector I reduced my budget by nearly 30% so I recognise this reality. Consequently, as I have said before, there isn't likely to be a huge degree of sympathy for those in the NHS who can 'sound' a bit like they're complaining about having to do what everyone else has had to do.

Mathew Parris did a challenging article in the Times last week talking about public sector 'whinging' that is worth a read - provocative but worth a read. I recognise some of his points - others I think unfairly diminish the commitment and passion of so many people doing a great job, but everyone is entitled to an opinion.

So I do understand how easy it can be to appear to be in denial that savings can be made, and be seen as unwilling to grasp 'tough decisions' wanting to blame everything and else and the governments at every turn. And it's true there are some inefficiencies and the way things appear to have always been done does need challenging and they can be improved without doubt.

But that is a long way from the full picture and it is a bit different in the NHS. What has surprised me moving from the wider public sector in to the NHS is the complex interaction of political micromanagement ( but not political strategy), governance arrangements, regulator micromanagement, commissioning arrangements, multiple providers, complex contractual and tariff arrangements, vested interests ( that don't always appear vested), etc etc.

I think the combined tinkering of governments since the 1980s, when the 'idea of a market' was introduced, and that has lead to this landscape, has now started to create a truly creaking beast.

And what's going to see it off is the load that 'beast' is having to carry, which is the inexorably rising demand - of an ageing population and other demographics.

And the proposed solutions are not only questionable in respect of whether they will be solutions ( or just cobble together even more complex bureaucratic arrangements) - but are questionable whether they deliverable in a timeframe that is going to make any discernible difference.

I think Chris' article makes the points very well.

Board, national voice and transformation

29th October 2015

A big board meeting yesterday with a huge agenda, which is indicative of the size of the challenges we face.

An important absentee, however, was our chief executive who had been called to give evidence to the Public Accounts Committee (as an aside one of our local MPs, David Mowat is also a member of the committee). Not sure it would have felt like this, but there is a sense of pride that 'our' CEO was asked to get involved, as it signals that the trust - and our team here - is widely regarded and get asked to get involved in many national pieces of work, as well as running the Hospitals.

A key issue, of course, remains our financial challenges and we spent considerable time pouring over our approach and the work going on to try to balance care, quality and cost - it's really is a rubics cube exercise, but there is huge effort taking place. We are working through a lot of savings and when we next visit Monitor, the Regulator, in December, we will need to explain in detail how we are going about this exercise.

The massive problem is that with hospitals, unlike many other services, you really can't just 'stop' the service or stop spending money especially on staff - as, at its heart, that's what a hospital is? The options and places to go to for savings are limited. And if people keep coming - and they do because of all the demographic factors that are well known - then you have to staff accordingly or patient safety becomes compromised.

Another biggie yesterday was discussion - and then agreement - to give the go ahead take a new patient record system live next month. This doesn't sound like the most exciting thing going on but, trust me, this is the biggest change in deploying how we use technology in years. We go live in late November and, whilst we have planned and hope for a seamless and invisible 'transition' it would be a bit naive to suggest hiccups are impossible.

Please bear with us as we make this change it really will be transformational going forward and worth the effort ( not to say the investment).

Lots of good stuff as well, a number of staff have been nominated for awards which we are thrilled about, our work on dementia is receiving national recognition and we have made good progress with infection control. Pleasingly we have also made big strides in our A and E targets and whilst not quite at the 95% target we are consistently very close to it and have been for some months now and this is a real credit to the people concerned.

Financial facts

12th October 2015

It's been a very big fortnight for us on the financial front. Nationally, Monitor recently released the figures for the financial situation of the NHS for the first quarter of the financial year, and it became clear that the whole 'system' faces major financial challenges. In short, and in ball park figures, it's about £1 billion adrift in just this first quarter. And virtually all trusts are in deficit or about to be in deficit.

This is a mind boggling amount of money - just to be in deficit? There are lots of issues around this but one of the big risks I think - strangely- is that with figures this big, it can create the illusion that this is a phenomenon that arises from modern society and so the answer in the end will be that more money will have to be found.

As a society we have always been prepared to put our hands in our pockets for the NHS and so why not this time? I am not saying that more money isn't required - eventually it almost certainly will be - and actually there are a lot of real issues that cost more. So to a degree there is a question of timing in relation to how much and when ( and I suspect linked more to a politically driven timescale than a health/ needs timescale).

But, that all said, there is also still a lot that can be done, and there are huge areas for greater efficiency - though it will require not just society but everyone in the NHS to think very differently to liberate that efficiency. Easier said than done. The tricky thing is that to release 'hard cash', I think, will also require much more 'letting go' of control from the centre, and much more freedom for local Trusts to innovate and to make local decisions; as opposed to increasing centralised control.

It's understandable to see the desire to control when money gets tight and the service is under a public ( media and social media) microscope. But it just won't work, because the system ( such as we can fairly describe that which exists as 'a system') is way too complex for prescription.

It needs agile decision making and risk taking - attributes that are anathema to ideas of regulation and analytical/ evidence based decision making.

In my previous life - the fire service - we achieved massive change - slashing fires and injuries, and we delivered massive savings. But that was achieved not by intensifying centralisation and standardisation and regulation. On the contrary, it was major deregulation and decentralisation and moving away from inspection and prescription to one of frameworks and focusing on outcomes that let local fire services off the leash to innovate.

This was not without its turbulence or problems and anxiety I should add - let's be real and honest. And not all stakeholders shared the same vision of the future - far from it; but there were pressing financial imperatives and ( in contrast to health) clear responsibilities and accountabilities to lead change.

So, decisions had to be made by those either in elected or appointed leadership positions - even if not always with the consensus of all parties. And the results speak for themselves.

I am still relatively new to the NHS and appreciate there is a vast amount I don't know and never will - but I would nevertheless contend that the fire and rescue service is not without its own risks and an element of danger and hazard? And so I think it does share some similar 'life and death service' characteristics with health and some of the learning from that sector is instructive.

But another tricky issue we face in health is something of an artificial conversation taking place and that is built on the assumption that everyone will eventually find ways to agree going forward if they continue discussing it? And organisations set up to compete with each other, will somehow just find consensual ways of designing a new future and transforming what we have. And in that brave new world everyone will be a winner and no-one will be, or feel like a loser.

Again, although there is huge effort going on to find new models of collaboration and cooperation, and much of the future must be based around these approaches - there is a limit ( set by the real finances) and so a world where everyone can 'win' is unrealistic. The trouble is 'who decides' the winners and losers when there is no-one in charge?

And win a deficit already at 1 billion and growing, and winter on the way, it's likely we will see more difficult circumstances leading to very difficult conversations.

Turning to our own Trust - last week we had our first meeting with Monitor colleagues, looking in detail at our recovery/ turnaround plans for Warrington and Halton and to address our local deficit.

A very very long way to go for sure, but it's fair to say that Monitor were pleased at the approach we are taking and the amount of work and activity going on.

Of course this was our first review meeting so no scope for complacency at all - and they will be looking again in a few weeks.

Still, it was nice to feel that all the work going on and the dedication and sheet graft of a huge number of people driving change locally is appreciated and acknowledged.

Support and constructive ideas

17th September 2015

We had our annual trust members meeting last night which was a really interesting evening and was reasonably well attended - in truth we rarely get massive turnouts to such events but last night's was definitely good.

We gave an update on our year - showing a short video we will make available on the website - celebrating some of the good things that have happened and, yes, there have been a lot of good things.

But we also talked openly and honestly about some of the difficulties and took a number of questions from members of the public who attended.

I think a few themes emerged that are worth sharing. There is huge support for the hospital and a very very large number of people have very positive stories to tell arising from the positive experiences. Up amongst the reasons for that is the professionalism and commitment of staff and I can only continue to commend everyone for that.

There is also a recognition that health has become highly politicised and that funding is a massive challenge; and our trust is very much amongst many other Trusts facing financial difficulties, not altogether of our making. And this isn't going to get easier.

So 'we' are not doing anything wrong? There are a few 'buts' as well as 'ands'.

But local people are really only interested in Warrington and Halton and want us to communicate better with them and not only better inform them about what is happening - and crucially why - but engage them more in some of the tough decisions and choices we must make. The governors council is really important here.

But people get frustrated at what appear to be 'odd' decisions - that may appear 'small' and not life and death, yet add a disproportionately negative layer to what is already often a tough experience. Car parking is a good example but there are others. So we need to ensure we look at what we do through the eyes of patients and in a more end to end way.

But citizens in all the other parts of their lives (as well as being patients) are also facing tough times and tough challenges, and so whilst they are supportive and sympathetic to our challenges - there is also an expectation that the leaders of organisations like ours need to 'figure out' ways of meeting those challenges. And for all we can explain the complexities that make this difficult, if we're not careful we can so easily sound like excusing something or obfuscating.

And so we do need to get more efficient and leave no stone unturned in seeking efficiency - and just get in with that - but at the same time we must not lose sight of quality and patient care and safety.

There is no silver bullet answer here clearly - but what is important is that in getting to answers we do so with as much engagement of local communities as we can.

Last night's meeting suggested a growing appetite locally for that engagement which must be a good thing.

Our annual members' meeting and enagement

11th September 2015

Preparations are concluding for the annual members meeting next week. For those not altogether familiar with the set-up of the trust, as a foundation trust our constitution lays out who can be a member which, in essence, is anyone who wants to be, and we really do encourage and welcome members and really need a diversity of people and point of view .

All our staff are members of the trust ( unless they specifically opt out - which only a handful ever have) and we also have around 12,000 public members, if you like members of the public; who then elect local people to represent the wider views and challenge the thinking of the board through being a member of our council of governors

It’s very difficult to get a perfect system of engagement - many organisations have tried and, believe me I have looked at many of these models over the years. The best of which, I think, is probably the John Lewis partners model (though there are also good commercial drivers for that model). So, whilst the members model here is a little different I still think that realistically and from a public sector perspective it’s really as good as it gets - and in any event, whatever model is deployed it is only as good as the participation of the membership.

Its patently obvious from everything I have said in my few months here, but more widely everything that is said by politicians and in the papers and the media daily, that the NHS faces unprecedented challenges (and I recognise that we can only use the word unprecedented once - nevertheless I think it is appropriate to use here).

Nice words like transformation readily get used, and of course there are some fantastic opportunities in relation to technological and medical advancements and developments. But there is also the serious and thorny issue of paying for the NHS and it’s obvious to everyone that the somewhat less pleasant word cuts will be needed; and people are understandably fearful about what any cut means to them at a local level. And they also want to feel confident that their money is being spent well and especially on the best patient care, and not wasted in the ways so often portrayed in the media.

Finally, they want to understand and feel confident that their trust is an open and accountable organisation, not in any way sweeping tricky issues under the carpet. On this last point I have been surprised by just how much suspicion there is - though maybe I shouldn’t be that surprised when I reflect on how much “covering up” still gets unearthed by investigative reporters about many organisations.

This annual meeting therefore is our chance to talk to our Members about a lot of this, say a lot more about where we are and how we are as a trust, describe what we think about many of these issues and, crucially, describe how we see the future. But it’s also chance to hear the views of our Members and to take their feedback on many of these issues so that as we do move forward at least we can do so knowing we have made every effort to take the views of people on board. And we can also make any improvements to our existing policies and systems, not least to try to dispel any idea of things being obscure and hidden.

Please come along if you’re already a member or just an interested member of the public - you would be most welcome.

Finances in the spotlight nationally and locally

Monday 17th August 2015

I am conscious there has been a lot of national media activity over the last couple of weeks about finances in the NHS and I thought it helpful just to say a few things?

The story relates to a letter sent by Monitor to all the trusts in deficit - and there are a lot of us – and it is reacting to the projected deficit for the year, which is now very significant nationally. The letter requests we do a number of things such as only fill essential vacancies, review our approach to Agency staff, look at how we roster staff, look at procurement and so on.

In a sense, I can see why Monitor have sent it, and the suggestions are appropriate, but really I think it is as much a signal of concern of the government as it is a clear set of requirements - as we are actively doing the things suggested. That said, the letter also seeks to increase the savings we are expected to find which will be very difficult indeed.

Locally, however, we are also shortly expecting a second letter that will be more specific and direct to us and outlining what we need to do at our trust in terms of the two investigations that have been taking place in to the reasons for deficit and A and E times.

In some respects, we think this will be a repetition of the more widely circulated letter, but there will be a number of additional and clear actions around the construction of the turnaround plan and also wider relationships with key partners such as Commissioners, local authority etc. I have said a number of times that, whilst there is a lot we can do as a trust (none easy I should add), it's generally accepted the solutions are much more about how the wider health systems work together. We will of course publish the letter when it lands (probably this week) and will work through and engage with our Governing Council.

Car parking remains contentious - there was a lot of media coverage a couple of weeks ago, and I did some stuff on the BBC which was extensively covered.

In many respects, this had a ‘positive’ effect as it demonstrated that we are being as honest and open as possible about the “harsh realities” but equally trying to be as sympathetic as possible. A key area of questioning was around the number of penalty charge notices not pursued, which were seemingly behind held up as an indication of error. For us, the reverse is more the case as we have cancelled notices as much on compassionate grounds as we have anything else. Nevertheless, our openness appears to have helped reduce the number of complaints.

On the same evening the CEO and I attended a health scrutiny board at Halton council where we had questions put to us for nearly two hours. Again, I think we answered honestly - and there were some fair points made and questions asked and we have asked them to forward any matters not covered so we can respond. They also sent a number of questions with a lot of legal background so we will respond to those in writing this week.

In summary, we are doing a lot still on better signage and have met the company to look at new machines but this will take a little while. We have had the British Parking Association review how the company conforms to the code of practice - and for all there are likely to be a number of recommendations, we understand these will be about being helpful rather than any question of being non-compliant. However, we have still asked the company to meet with local trading standards officers to work through their issues and concerns before the DVLA restart providing data. We will continue working with patients, governors and key stakeholders (we want to meet the CEO of the Disabled Drivers Association as part of this), and we are also reviewing the policy again to ensure we have been as fair as possible to all groups.

A couple of other things are worth mentioning as they have been keeping me busy.

I continue to follow a programme of meeting chairs of other trusts around the region to discuss what they are doing, and the challenges they face, and also where there are opportunities for collaboration and working together. I continue to meet regularly with key partners and indeed trying to escalate the level of awareness of some of our challenges ( linking to the point above about systems solutions). And I also continue still to find my feet in understanding the mini community that works across our two hospital sites as well as make key appointments to senor roles as a number of our executive officers have been successful in being “promoted” elsewhere.

There is a huge amount of frenetic activity but what continues to impress and inspire me is that, despite all the “stuff” going on there remains a real passion and commitment to patient quality and patient care - thank goodness.

Parking Update

Monday 27th July 2015

Sadly the 'car parking issue' continues to dominate conversation at the moment, and so it remains important to try to be clear to everyone – not least our patients and visitors - where we are. There are really four 'big' issues, which I want to deal with in this post and in turn they are as follows.

1. The ease of paying for parking and the signage clarifying what people should pay

There is little doubt that, with the benefit of hindsight, we could have introduced the changes better, with bigger and/or simpler signage to be more helpful to people. Whilst what we and our contractors have done complies with the relevant codes and guidance, compliance is not the same thing as being helpful.

So, rather than be in denial we have acknowledged this.

We have set up a working group led by the independent Council of Governors (as public / patient representatives) to co-ordinate feedback. I would publicly wish to thank them for their work so far. In addition our patient experience team have been working with visitors and patients to understand their views and I have personally talked to many people on the front line, to our complaints team, to those in the cash office and others. The collective feedback 'broadly' reflects the point that the signs may be compliant but could be more helpful.

Rest assured we are doing a lot of work on developing new signs, on the role of volunteers to be more visible, on new payment machines and so on. In other words we are working a range of improvements. Things won't happen overnight but I hope you will see changes coming forward and that we have genuinely listened to concerns.

2. Challenges for our contractors in relation to penalties following non-payment of parking charges.

The introduction of issuing parking notices has been the biggest issue and has raised real concerns with people. At one level, we need to be honest, there are people who don't agree with paying and want to make a stand on this point of principle. I am really not sure what we can do about that, as 'philosophically' I suspect many of us would agree. But, as I have said before, that is not where we are across the NHS and standing on a 'principle' is likely to be expensive.

However, at another level, there are also a lot of people confused and anxious. So we have truly tried to reflect this in our approach to listening when people appeal their parking notice. Ironically, the fact that we have tried to be sympathetic when people have given good reasons during their appeal has then been suggested to be indicative of a failing system because the appeals succeeds. Again I’m not sure we can win on this, save to accept that there can be genuine mistakes and circumstances that are 'unique' and so we do need to listen and we are doing so when it is appropriate.

However, we also still need to continue to be honest that issuing parking notices to people for not paying will continue to be part of our approach as it is for so many other Trusts and organisations outside the NHS.

3. The range of legal challenges around planning permission and use of data

There are a range of challenges which is creating a lot of tension and ambiguity. For example, there are suggested issues about camera location, signage and wording of penalty notices specifically to mention but a few.

In this respect we went through a full tender process requiring the relevant organisations to comply with the relevant guidance and legislation. We understand they do. If it transpires they don't, then obviously we will take a view but it's important to state there was a proper and extensive process undertaken.

However, in keeping with being open, we have met a number of key stakeholders to get their views and we have commissioned a site survey by the British Parking Association as well as asked the Trust governors, staff and patients to undertake site visits.

This has indicated so far that it's likely there are some issues to 'tidy up' on the technical side. For example, it has become apparent that there is a stretch of adopted highway on Trust land, dating back to the 1970s, for which the records were obscure. However as it stands our understanding remains that what we have done across our sites and what has been done in our name complies with the relevant guidance. But we must keep an open mind and we are still receiving questions, information and challenges to this. So we will need to work through them all properly. I am ensuring that we are doing.

4. Reputation

We are under no illusion that this has been and remains damaging to our reputation. I have already publicly stated that it's virtually impossible to change parking regulations in a way that attracts support. However, there is also little doubt that the consequences and scale of negative reaction could probably have been anticipated.

Over the last few days we have met many people and groups - local councillors, our governing council, local MPs, local planners, trading standards and the companies concerned. We are also attending Halton council very soon to talk about this and to answer questions in an open way.

But we know we need to things as quickly as possible. As I fear all the excellent work we do at the hospitals in relation to patient care could easily be overlooked because of the emotion of the parking issue. I hope this blog shows how seriously we are taking this issue and assures people that we are doing a lot as quickly as we can.

I am really encouraging our staff not to be passive on this, rather to be up front in talking to our patients and explaining and clarifying where we are, and what we are doing. They are after all the best ambassadors of Trust.

But it also remains important for all of us not to lose perspective and not to lose sight of the other, truly significant issues we are dealing with – providing high quality, safe caring for those people that need our help each and every day.

Caring and effective - but with improvements to make

July 10th 2015

We have now received our CQC report from the inspection earlier in the year and it has been made publicly available today.

Overall, there is a lot to be pleased about - as there is a lot that the trust is commended for and examples of best practice highlighted; in particular the caring approach, attitude and leadership/ professionalism of the staff encountered. And this very much reflects my own experiences in the last few weeks.

In a way, it's a shame that the method and the way the scores tally up result in a 'requires improvement' overall, as I suspect that will be the simple headline grabber. And that makes it unfortunate that the rest of the report may not then be read in order to get the full appreciation.

And I also know from speaking to staff (for example I spent the afternoon with colleagues in and around the operating theatres the other day) that there are some frustrations around this - and people can feel that maybe they don't get the recognition they deserve.

But regulators are not really there to celebrate success - rather they are there to ensure a safe and reasonable level of service across the piece. And so we shouldn't let any small frustrations or irritations detract from the report or distract us from saying thank you to everyone for what was clearly an amazing team effort in preparation and during the inspection - but of course for continuing that in the many weeks since.

Clearly, there are areas we know we can improve and the report draws attention to these, and we are starting to action them already. Further, we may get a no notice inspection at any time going forward. But, still, it's nice just to stop for a moment, draw breath and say thanks and well done before entering the 'fray' again.

And talking about entering the fray it's worth mentioning a couple of other matters occupying my thoughts and activity this week.

And I really can't avoid mentioning car parking in this context.

We were never going to get plaudits for changing the approach to car parking - and we anticipated something of a backlash. The CEO and myself took questions from our governors the other evening, and it's fair to say there was a huge amount of negative feedback which is indicative and reflective of the level of complaints received (though I should add that there were governors who had good stories to tell as well). We have also received similar negative feedback from councillors and MPs.

Unfortunately, we simply can't just change policy in response to media reports and the fact that people are not 'happy' about paying for something. Actually, I think we can all agree that people shouldn't have to pay to park at a hospital. But we can all agree with notions that we shouldn't have to pay for lots of things provided in all manner of public services.

Indeed, in my previous life - in some circumstances - we charged a fee for responding to what the people involved saw as 'an emergency', but really wasn't in the context of the resources required and distracted from other things. So there is a financial and political reality of life that must be dealt with and whilst I think most people get this intellectually they are still, nevertheless, frustrated and irritated.

We also have to have a real appreciation of the problem and retain a sense of perspective (we have nearly 100,000 vehicle movements on our sites every seven days and complaints about parking represent a tiny percentage of this figure).

But that all said, equally, we can't and shouldn't ignore the feedback from key stakeholders and patients - and the damage to our reputation either. So, we are not stopping or suspending anything to do an 'urgent review', as that would inappropriately raise expectations that a significant change is likely or possible. And for all this is controversial and unpopular the financial facts of life mean little of substance can or will change.

On the other hand, nor can we be belligerent to patients (and staff of course) or uncaring and I therefore think we must accept and recognise there are some issues to address and probably things we can do to ease the situation. For example, better signage and explanations, greater clarity about fines and so on. So, whilst not stopping, we are in a state of regular review of the situation. We have also invited our governing council to spend time looking at the issue, we continue to meet the organisation managing the car parking and we will make any sensible and reasonable changes and adjustments to the policy as necessary.

Meanwhile, we still have the small matter of running the hospitals and the trust, improving our A&E targets, addressing a serious financial deficit and bringing in a major new computer system over the next few months (to mention but a few issues) to attend to.

And in this bigger context a board delegation spent a few hours at the Monitor offices this week, being questioned as part of their two investigations in to our financial situation and A and E performance against targets.

This was a tough time and they leave no stone unturned for sure. But, I should also state that this is entirely appropriate and it should be that way - as we must always be cognisant that it is tax payers money we are spending. As much as we need to be held to account for patient care, quality and service that can't be at any price.

So I have no beef with Monitor's approach to their investigations, and my reflection was that whilst we all would rather not have had to be questioned - the style was courteous and reasonable and the questions themselves perfectly fair.

We will hear either next week or the week after what steps - if any - Monitor will take next but I left the session pleased that we could not have been more honest and open, or missing something. Monitor colleagues were appreciative of our straightforwardness and appeared somewhat reassured that we had matters in hand, we had a sense of 'grip' of the situation and we were developing a plan and building the capacity to deliver the plan over the next couple of years.

Whether they were reassured enough is the question.

Could I close by saying thank you again to everyone for the work behind the CQC visit in January and the care they provide each and every day.

Parking matters

20th June 2015

I’ve read with great interest - and to be honest concern - the comments and difficulties that some of our patients and visitors have experienced with the parking system at the hospitals which was introduced last year - the number plate recognition system.

This system was introduced to help us manage parking at the hospitals in a better way, and, by doing so, we’ve been able to introduce new parking machines, chip and pin payments, pay by phone and the ability to pay on entry or exit from the hospitals without displaying a ticket.

In fact, for the vast majority of people coming to the Hospital, there has been no change to the system that’s been in place for around 10 years, other than they now have to enter a registration number when paying.

Contrary to some comments, the prices haven’t been increased with the new system, and there remains a maximum charge of £5 for 24 hours.

I think the thing that is different is that if people do not pay for the time that they are on site, this will now be automatically picked up - rather than there being a question of chance previously.

I appreciate this can be frustrating, and in some ways it can feel really unhelpful for people to have to “pay” for something which they believe should be free. In many ways we wish that we didn’t have to charge for parking - but there are financial realties and every Hospital is in the same positon.

We have been very open and honest about the changes, and that we made decision to charge for “blue badge holders” when we brought in the new system. But we have tried to ensure there are safeguards in place to prevent this being too punitive. And so for regular patients and visitors there are concessions that reduce the cost to parking to around £1 a visit. There is also a national hospital travel cost scheme that can refund costs for those on low incomes and details of this may be found on our web site.

As well as everyone now being registered when they enter the site, though, the number plate system now also means that fines are being issued by the Company who manage the car parks on behalf of the Trust – Highview Parking. Previously, fines were not really issued.

Again this is a common approach with other Trusts - as it is for local authorities more widely - but here too we have tried to put safeguards in place. And where there has been a genuine error on our part, or the user’s part, we have put in place an appeal system that is fair and balanced. This approach has quashed a large number of fines - but it’s also fair to say that good cases do have to be established and it’s inevitable that some people will remain dissatisfied.

Finally, it’s important to state that the money that we raise through parking is not just an added extra - it is an integral part of the budget and pays for the transport and parking costs we incur ( by “we” I mean the Hospital Trust not the staff who pay for parking as well). Anything extra goes into the main patient care budget as has always been the case.

As mentioned I acknowledge absolutely that in an ideal world, all parking would be free for everyone but it is an essential part of our budget planning at a time where NHS finances are incredibly tight.

No-one wants a poor experience or a threat of a fine to overshadow the care that is provided at our hospitals - and if people feel that has been the case then I genuinely regret that. What people do have my commitment and that of the Trust Board that we are working with the car parking management - Highview Parking - to ensure that the system is fair and transparent, working correctly and that it will continually be improved based on patient feedback over the coming weeks.

Conference season and fair expectations

16th June 2015

I recently attended the NHS Confederation Conference in Liverpool - my first such event as chairman - and it was very interesting. A good chance to meet other colleagues and also to engage first hand and interact with the Secretary of State Jeremy Hunt and the NHS England CEO Simon Stephens - as well as think about the wider transformation challenges.

It has always fascinated me how the 'vibe' and mood music from conferences like this permeate back to organisations and set a tone for the future direction - and you can sometimes ask yourself whether you were at the same conference as others?

Just around the time of the conference each trust received correspondence from the Department of Health and regulators around the issues of executive pay, and arrangements around people retiring and being re-engaged, and also the use of management consultancies and the costs associated as well as a few other matters that can be controversial (not surprisingly controversial) with the public.

These letters seemed to create a high degree of noise; with many seeming to feel that the commentary and language by the key speakers was inconsistent with the tone of the correspondence.

But the biggest themes of the conference were really a reinforcement what we already know and I think had three strands:

  • The Secretary of State stressed that the NHS was going to see an extra £8 billion - and notwithstanding the projection that demand will cost £30bn it is still nevertheless more money - and that is a luxury not being afforded to the majority of the rest of the public sector
  • The integration of health economies is still seen as the answer - but it will still be for local health economies to figure out for themselves what this means
  • (These are my words and interpretation) There will be few carrots and quite a lot of stick for those who fail to deliver - with the use of intervention being seen as the answer in many cases.

From my perspective - maybe it’s because I am new - some of the reaction to this seemed a little puzzling - colleagues felt that it was a tough stance when set against the challenges faced over the last few years and didn’t seem to give the credit that is deserved for what has been achieved.

But I didn’t hear that - I heard the Minister and CEO celebrating fantastic work done across the NHS - but at the same time trying to get all the key players to read the writing on the wall and provide a call to action.

And, returning to the idea of pay and consultancy costs - it strikes me that when the media - nationally and locally - is full of stories about financial crisis and investigations, then it’s only natural that tax payers are going to expect tricky questions to be asked about this kind of stuff.

For example, if a trust is spending hundreds of thousands of pounds on management consultancy, when they are running a big deficit (as we are), then I think it is absolutely right and proper that we should be prepared not merely to explain why we are doing this - but, yes to justify it as well. And it’s also right and proper that the regulators assure themselves that the trust is gripping the situation and will take the necessary action to do so - it’s a matter of public trust and confidence as much as financial stewardship. All I would seek is a sense of fairness and equity - and reasonableness in approach.

I felt quite comfortable that it was spelt out as nicely as possible - but as clearly as possible - what the expectations are of us from the Government and NHS England. Maybe I will be less sanguine next year? On the other hand, maybe I will think it was a helpful staging point of clarity.

Looking forward

28th May 2015

So, this is my second blog - it's just a few weeks in to my new role, but what a few weeks it's been.

The Monitor investigation working with us to look at our finances, the General ( and also local) Election, supporting work on our longer term strategy by KPMG and a couple of senior appointments/ impending departures as colleagues move to pastures new, to mention but a few things. In respect of the last point could I congratulate Roger Wilson on his appointment to our HR role and Simon Wright on his success on achieving a CEO position.

In addition, we have also been trying to work through negotiations with commissioners, agreeing the final settlement for financial year 2014/15 and the projected financial requirement for 2015/16. This is not easy stuff and there is a huge amount to think about from the strategic perspective - and of course we have continued to cope with extraordinary demand across the trust's activities.

There are a number of ‘practical matters' that flow from these issues and I want to say more about these below. This is not to worry people or to be gloomy in any way, on the contrary I already have a strong belief that we can deliver. But I am a big believer in a consistent telling of the truth and being honest with people about what we need to do. I find people can handle tough situations, provided they are not sugar coated and provided they understand not just what they are being asked to do - but, crucially, why? (I am afraid this does mean that it's quite a long blog - sorry about that.)

There is no doubt, following the election, that very big change is required and there is equally no doubt we are not talking about tweaking at the margins - we really are talking about system change and transformation. And, though we have used this word transformation a lot over the years, what it will mean going forward does need to be seen in a different context to what it has meant in the past.

During the election all parties were somewhat less than forthright in expressing the 'true' situation facing the NHS, as the commentary and analysis since has illustrated. Much of the debate at the time centred on a way of finding or committing an 'extra' £8 billion for the NHS. But, as I suspect most people recognise and, although there are many ways of using the maths to come up with a real figure, it is nearer £30 billion required than it is £8 billion.

The difference is to be achieved by liberating "efficiency" and delivering transformation and here is a link to one (amongst many) analyses of the 'problem' - http://www.health.org.uk/publications/hospital-finances-and-productivity-in-a-critical-condition/

These are eye watering figures, whichever way you look at it, and reinforce the imperative of advancing change at pace. KPMG will be reporting to us shortly, and Monitor are understandably taking a keen interest in the work; but, actually, I strongly suspect there will be few surprises in general terms - though the detailed analysis and work is vital. What we will need to do is quickly assimilate the KPMG commentary, then work up an action plan to implement the changes necessary to get back to a financially sustainable position ( although as the brief overview above illustrates it is not possible to get to this position without the system change I will talk about below).

Whilst implementing an action plan is an easy thing to say - it's much less easy to deliver, not least as it will be an action plan running for many months, probably into a couple of years realistically. It will also require relentless focus and concentration on change programmes, at the same time as continuing to deliver key services for patients and under quite intense public scrutiny.

I heard the analogy 'changing the spark plugs with the engine running' and I think it captures the challenge very well. In order to try to ensure we have the right practical, project management arrangements in place to oversee this, and to get ahead of things if we can, we are also now undertaking a rapid review of the board's governance arrangements.

In doing this, we are trying to figure out how to ensure they are fit for purpose and how we can collectively provide the leadership necessary at board level (and to reassure our regulators that we are serious about taking on the challenge). More importantly, it’s about how we support leadership and participation at all levels with an approach that engages and brings everyone with us instead of feeling like things are being 'done to them'.

We don't underestimate the task here, so the review is not just an interesting and abstract look at things - it's already certain we will put in place new arrangements, so it's more to do with what the changes will be, rather than whether we change. We have committed to completing this review in time for discussion and agreement at the June board.

Turning to the wider health economy - as mentioned, it's simply going to be impossible for us to devise a sustainable financial proposal for the trust in isolation. Because even if we deliver everything on the action plan we will get from the KPMG work, it will still not meet the financial challenge ahead.

This reality has two implications. One, we really do have to deliver the efficiencies because if we miss our targets we just make the problem bigger and increase our risks. Two, it becomes vital that we have a clear vision and strategy for the wider Warrington and Halton health economies going forward - and something that is shared and owned across both the commissioner and the provider networks.

Intellectually, it's quite easy to agree on the concept of this but the practical realities of the changes everyone needs to make are something different and are truly difficult. Especially when one considers that we have all already faced huge challenges across public services and we have all also already endured huge cuts already (for example local authorities have seen budget cuts of nearly 30 percent and with more to come).

Everything is relative - but there is a real risk I think of each party looking inwards and feeling frustrated, but then looking at each other in an 'our cuts are bigger than yours’ way. This would be an approach which, whilst understandable in many ways, would nevertheless be destined to lead to inertia and possibly resentment; rather than the collaboration and innovation necessary to succeed.

In this respect, therefore, we have been in conversation for some time with our partners in both Warrington and Halton, and we have invested a lot of time and effort building the strong relationships necessary to collaborate going forward. And whilst we have achieved a sense of common purpose around better healthcare, we haven't yet translated these good relationships in to a unified clarity of vision or, indeed, joined up our respective operational strategies across all the networks. In other words, we haven't yet devised the end to end integrated care strategy.

But then again we have had huge operational challenges, we have had the policy ambiguity of a general election and there needs to be a sense of realism about the art of the possible. And, to be fair, we are well on the way with good progress being made.

So where does all this leave us? I genuinely believe it leaves us in as good a place as many, better than a lot and not quite as good as some, but with a great opportunity to grasp the way forward - and, crucially, with the right people and relationships to do so.

But it also leaves us with big issues to address and a need to 'crack on' as, for all the change will take months/ years there is an incremental curve here. Avoiding tough decisions early will have a negative and compounding effect in years to come. Conversely, taking hard decisions now - however difficult they may feel - will bring the benefits we need down the line.

Two things are sure though - firstly, 'we' have a big job ahead; but, secondly and thankfully everything I have seen and everyone I have met convinces me we have the talent, ability and attitude to do the job we need to do, and do it well.

A warm welcome

21st April 2015

This is my first blog as Chair - something I hope to do reasonably regularly.

I am conscious in doing so, however, that there are many different audiences - staff, patients, public and stakeholders amongst them - who might read this so I may struggle to hit the right tone and pitch for a while. We have incredibly busy facilities at our Warrington and Halton sites (not forgetting colleagues at other sites such as Bath Street also), and in many ways staff have their heads down getting on doing a great job; so their time is at a premium.

So, against this backdrop of activity and speed, the level of understanding of what ‘the trust’ is and does - and what people like me and other non-executive directors do - will be very mixed. Indeed, the level of interest and perceived relevance will also be very mixed - as the focus and gaze of nearly everyone towards the effective management of the trust will - quite rightly and properly - be with the CEO, Mel, and her team.

Of course, I have no wish to dilute that or confuse in any way (we have enough confusion for sure). However, I do want to start to help communicate a little more about the trust and its relationship to our wider community and stakeholders and, over time, not only help build awareness of what we do in terms of the strategy and performance of the trust, but also how we are going about developing our thinking about transformation and change in so far as it affects Warrington and Halton. The services we provide must fit into a wider health economy - but as we are all too aware from the general election fervour, a wider economy and wider public realm also.

In the first few weeks my time will be very much taken up finding my feet and absorbing as much information as possible and trying my hardest to get out and about as much as possible. For example, I spent a fascinating few hours in A&E last Friday night (I would have stayed a bit longer but they were getting busy and I was keen not to get in the way - amazing job being done by the way).

However, there will be constraints on this learning exercise as, at the same time, we are in intense negotiations with our commissioners not just about the current year’s financial situation (which is extremely challenging to use a pithy phrase) but also still about settling for last year. In addition, we have KPMG doing work to help us shape a strategy to turnaround our finances (not something we will be able to do overnight) and liaising frequently with Monitor in and around this work - and we are ploughing through the draft CQC Inspection report.

Please bear with me, therefore, in getting my face known more around the Hospitals - but also please feel free just to say hello if you see me wandering around (looking lost I suspect).

As I mention I would hope to do these things regularly but the regularity really depends to a degree on feedback - whether people find it helpful or just another “thing to read” - so please feel free to provide feedback to me.

The final thing to say here, though, is just a huge thank you. I have been a little overwhelmed by the welcome of people, by the professionalism and dedication of just about everyone I have met - as well the passion of people to deliver the best services possible. So, genuinely, thank you for all that - my first few days have been highly informative but highly enjoyable also.

I recognise entirely that there are huge issues - but I have never been one to duck a challenge and it really does strike me (quite quickly actually) that for all there are systems and issues that seem to defy logic (to put it kindly) - what we do have is the people and capability and will to carry on doing amazing things and figure out ways to make things work.

I think my role with my NED colleagues is to enable that culture of resourcefulness - and, sometimes this will be by asking tough questions and making tough decisions (that is reality and we can’t and shouldn’t duck that) - but I can reassure everyone that it will also be with the best interests of patients (our families and friends) at heart, and underpinned with huge respect and massive admiration for the work people here do.

I am really looking forward to working with everyone.

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