No Going Back

Watch our video that features staff talking about the role they played in making some of the changes happen.

We’ve witnessed incredible transformation take place across our hospitals as we deal with Covid-19. Thanks to the brilliant and fast-paced work of our staff we’ve achieved some remarkable things, including:

  • Holding 5,700 appointments over the phone in April – meaning fewer patients had to come to hospital
  • 20 wards were transformed to care for Covid-19 patients at the peak of the pandemic
  • A five-fold increase in our critical care capacity
  • Cancer treatment and trauma care moved to nearby ‘Covid-free’ hospitals to keep patients safe and continue their treatment
  • Psychological support for our staff in person and over the phone from a team of psychologists
  • More than 1,000 ‘Thinking of You’ messages delivered to patients.

No Going Back infographic

No Going Back delivery programme

Purpose

The NHS has faced and risen to its greatest challenge since its inception in 1948. With phenomenal dedication, commitment and professionalism, teams in all areas of health and care have rallied to meet the new and un-anticipated demands of the global pandemic. Almost overnight, many positive changes and improvements have been made in response to the crisis, including increased levels of digitisation, rapid reconfiguration of services, innovative workforce re-design, agile decision-making and increased collaboration.

The purpose of this document is to define the specific programmes that together make up our No going back delivery programme. It describes our approach to meeting the operational challenges of Phase One of the global Covid-19 pandemic and it offers a stocktake of our learning and of the beneficial changes that have been brought about by the ongoing Covid-19 response and what enabled those changes to be made. It also describes the significant ongoing challenges we will face in delivering our response to Phase Two and what that will mean for the form, function and approach of the way we will do business.

We cannot respond alone. We are part of a system – the East London Health and Care Partnership (ELHCP), working with NHS London. The current centralised command, through local ‘cells’, Integrated Care Systems (ICS) and regions has been effective with organisations accepting a level of control that would have been resisted in the past. It has been judged to be highly effective and is set to continue for some time to come. What will replace what is known as a Level Four command structure is a live discussion, however it is felt unlikely that we will go back to how things were before Covid-19.

The ELHCP ‘Acute Care Cell’ is provider-led by the CEOs of the three acute hospitals. BHRUT is leading the North East London (NEL) Elective Care recovery plan. Covid-19 planning and delivery has simplified governance and replaced commissioning and complex assurance arrangements with provider-led leadership. Over time, as power shifts from central command to the ICSs - and providing we continue to play our part with reliable, credible delivery - then our ambition to deliver highly reliable, high quality integrated provider services and to be an anchor organisation for Barking and Dagenham, Havering and Redbridge (BHR) will become increasingly more likely.

A key message is that Phase One (the experience of recent months) has been delivered with purpose, an amazing staff response and considerable public support. Phase Two, over the next 18 months and beyond, will be different. Changes have been delivered in Phase One that would have been either unthinkable or very difficult to implement, in pre-Covid times. The backdrop of an economic crisis, requirements for greater productivity and agility, staff fatigue and possible public frustration all mean that plans must be developed now, and action taken now, to build on the momentum of Phase One. Consideration must be given not only to restoring services (electives, OP, diagnostics, screening, training etc.), but also to catalysing opportunities for transformative change.

Introduction

“The way our staff and our organisation have stepped up”, wrote one of our senior consultants “has been a fantastic display of the true values on which the NHS was founded”.  United by a common goal – to mitigate, as best we can, the impact of Covid-19 – our doctors, nurses, and healthcare assistants; our porters and our cleaners; our admin, IT, corporate, procurement, estates and pharmacy staff; and our AHPs, therapists and scientists have all, together, transformed our Trust.

Its present state is totally different to its recent past.

Three months ago, our outpatient departments were operating in ways that had not changed for decades. Last month, almost 5,700 appointments were held over the phone. We moved from having three Covid-19 wards at the start of the pandemic, to running 20 as we neared the first peak in the number of infected patients. We protected those with cancer by moving their treatments to a ‘Covid-free’ nearby hospital and we did the same for people needing trauma care.

At our hospitals, as our teams dealt with what one of our doctors described as a “brutal and relentless” virus, we increased our intensive care capacity five-fold. Such a bald, factual sentence doesn’t begin to capture what an extraordinary achievement that was, and the same teams who achieved that feat, also managed to get a renal dialysis unit up and running in critical care in just ten days.

All this, and more, was achieved – in part – because we simplified decision-making; moved at pace; and empowered our staff to deliver. The pressing need was for our employees to be flexible; agile; and to work in multi-disciplinary teams in areas where that wasn’t always the norm. We weren’t left wanting. All our doctors have embraced a rota that ensures care is delivered 24/7. Nurses in outpatients overcame their understandable concerns and learnt new skills in ITU bringing their immense experience to the team.  Seven-day working is now undertaken by, among others, our physios and our children’s nurses.

Vital staff testing was delivered by pathology, HR and occupational colleagues working together. As well as monitoring our spending, those in finance have helped our visitors at our front doors and set up a production line to aid the creation of more than 25,000 goggles and 3,000 visors.

Time and again, people have left their comfort zone and taken on, with relish, new ways of working.  Callum has swapped a desk-based role for one where he clocks up 20,000 steps a day delivering personal protective equipment (PPE) to our staff. Coral has moved from sexual health to working on a ward for the first time in ten years.  And Mercia caught one of the last flights out of South Africa so she could re-join our Trust and work again with our infection prevention and control colleagues.

And we weren’t alone. The support from right across BHR has been amazing and humbling. We’ve had vital assistance from, among others, Mayors, councillors, community groups, Lions Clubs, Rotary Clubs, cafes, electrical firms, food stores and many other businesses. One furloughed taxi driver has devoted his days to collecting hot food from an Indian restaurant and delivering it to our hospitals. Members of the public have been knitting, sewing, running and walking – to raise funds to support our charity.

Our charity has played a key role supporting the needs of our staff. One aspect of their work has been to coordinate and distribute the extraordinary range of donations we have been privileged to receive. These have included in excess of 100,000 portions of food and drink; 12,500 Easter eggs; and sofas for our staff to use in our wellbeing rooms.

The pace of change has been exhausting and extraordinary. BHRUT after Covid-19 struck, bears little resemblance to how the Trust functioned before. We’ve filmed some of our staff so they can better articulate their experiences and their desire not to jeopardise what has been done as we now seize hold of a once in a generation opportunity to improve care for the better.

Slogans, at their worst, can be vacuous. At their best, they capture the essence of something and lodge in the brain. As the new BHRUT moves forward, as part of a new NHS, it will be guided in the coming months by three simple words: No going back.

The No going back programme is therefore best described by the questions it seeks to answer:

  1. Is care safe today?
  2. How do we retain resilience to deal with on-going Covid-19 and pandemic needs?
  3. How reliable are our current delivery systems?
  4. How do we do everything we can to minimise excess mortality and morbidity from non-Covid-19 causes?
  5. What information can we use and share to help with real-time sense making and action?
  6. How do we return to the right level of access performance for elective cases prioritised by clinical need?
  7. How effective are we?
  8. How do we ‘Lock In’ beneficial changes that have been collectively brought about?

Clinical summary of the pandemic

Our lessons, learning and experience

A number of significant changes were made in order to respond to an expected, significant increase in the number of patients being admitted to our hospitals and the anticipated demands on critical care facilities.

In the initial stages our hospitals were full with “business as usual” patients. In response to national directives and working closely with our community and social care partners we transferred patients, who had completed medical treatment, to their homes; into rehabilitation; or to a convalescent type facility until they would be ready to return home.

In response to the need to protect patients we changed the configuration of emergency departments (ED) at both of our hospitals so that we could see patients with potential Covid-19 in separate areas from patients who had other reasons to attend the ED. The configuration of our hospitals also changed to enable us to create cohort wards for patients with Covid-19 separated from other patients. This also applied to our intensive care units.

We increased our intensive care capacity by creating additional spaces for critical care and training a significant number of staff to work there under the guidance of our intensive care doctors and nurses.

A workforce hub was set up which has enabled us to manage staffing of wards and other facilities across seven days of the week. In addition, support teams, such as an expanded deteriorating patient response team, were created. Medical rotas to support care of patients across seven days a week with increased consultant presence 24 hours a day were put in place. This included deployment of staff to unfamiliar areas of work.

All of this required us to put in place training in a number of areas where there was a limited knowledge of the disease. These included:

  • Critical care training course
  • Covid-19 training package
  • Training in use of PPE

A significant number of guidelines relating to care and treatment of patients with Covid-19 were developed locally or received from national bodies and the London Clinical Advisory Group. These have all been managed through the creation of a Clinical Reference Group attended by our clinical leads which is held twice a week.

Some activities have also reduced or changed from traditional models of care. In the early stages we paused our non-critical cancer work for a two-week period to allow our cancer teams to re-organise care for patients including the transfer of chemotherapy work to a local private hospital handed over to us for our use. It also allowed cancer clinicians to re-plan treatments for some cancers in response to emerging guidelines. Cancer surgery has also had to be managed in a completely different way with some of our patients being taken to central London private hospitals to be operated on by our surgeons in a safer environment.

We saw a significant reduction in emergency attendances at our hospitals across all groups of patients. Whilst some of this may reflect the societal changes that have taken place during this pandemic there is concern that some patients with more serious illnesses had not felt able to seek help. In particular we saw a very low number of paediatric patients attending the ED at King George Hospital (KGH) and very few admissions. Decisions were taken to close the paediatric in-patient unit at KGH and transfer those few patients to Queen’s who needed admission. (This was a practice adopted by a number of other London hospitals). An ED service for children at KGH has been maintained throughout this period. We also transferred all emergency surgery to Queen’s following a senior surgical assessment at KGH due to low numbers of patients requiring emergency surgical admission.

In the outpatient setting, we have deferred some hospital appointments, but teams have been working to ensure virtual or telephone clinical appointments can be made and, where needed, a “hot clinic” involving a face to face appointment can be offered.

On a daily basis, our Silver and Gold command structure has enabled us to make rapid decisions and change patterns of care. It has also enabled us to ensure critical supplies of oxygen, drugs and equipment have been made available to our patients and our staff.

We have learned that our organisation can respond to an unprecedented change in care for patients in a pandemic. Building blocks for much of this change were already in place - for example, we have long had an ambition to increase our support to our GPs with advice and guidance services, or with virtual appointments. We have also learned that it is necessary to be agile in the face of emerging predictions of change. A repeated quotation that has been heard throughout Phase One of this pandemic is “to prepare for the worst and manage from there”. Care for staff as well as patients has been paramount and the need to listen to all of our staff has been critical to our pandemic response.

We need to retain the learning from this phase of the pandemic. Some of this learning has included:

  • Increased capacity in critical care for future preparedness and in recognition of the fact that critical care capacity in London prior to the pandemic was not ready for population changes
  • Collaborative cross sector working enabled rapid learning and response to this crisis. This applies to local system working in assessing and managing patient discharge from hospital as well as learning and collaboration at an ICS level
  • Well supported staff and appropriate staff rostering is effective in improving quality of care for patients
  • Awareness of the importance of infection prevention and control which will form a cornerstone of our next steps in planning care
  • Virtual consultations and support to primary care can be delivered in a very different way in the future. This will also apply to our approach to diagnostic testing as well
  • There may be unintended consequences from the rapid change in clinical care and service. We have seen an increase in outbreak of multi-resistant bacteria in some of our critical care patients during this period. Causes have been multifactorial
  • We restricted visitors in line with national guidance which meant that we had to transform the way we communicated with families and change the way families and friends communicated with loved ones during this time. Some of this involved using donated iPads for video calls and setting up a Thinking of you service for people to send in messages that we then deliver to our patients. We have received more than 1,000 such messages via our website.

We now face a number of challenges for the future

Our thinking on how we deliver health care will be dominated, at least in the near future, by the need to plan care with infection prevention guidance at the forefront of our minds. This will drive decisions on how we configure our hospitals to ensure that those patients who need planned care can be checked for risk of infection before attending our hospitals or for admission for elective procedures. And once admitted, we need to ensure they can be protected from risk of cross infection from staff or patients who may have the infection. For those who have an urgent or emergency admission, a quick decision will need to be made on whether they have been infected or not.

We have been testing those who are admitted as an emergency for some weeks. We are also testing negative patients, prior to discharge to care homes and residential accommodation. This will need to continue. We also have an established staff testing programme for symptomatic staff members or their households. In future we will be challenged to increase testing for elective patients as well as potentially increase routine staff testing. We await future guidance on antibody testing and its role in determining the implications for staff and patients.

During the peak period of Covid-19 we deferred some routine appointments and routine elective surgeries for patients, in line with national guidance. We are now looking at all of our patients on our waiting lists. Clinicians have been asked to undertake clinical prioritisation of waiting list patients in line with the Royal College of Surgeons and NHS London guidance. We are working across the ICS to begin to step up planned surgical lists, in line with infection control guidance, for our more urgent patients.

How our clinical expertise has led our decision making

At the start of this pandemic there were no clear treatments available. The focus was on supportive care. Our teams have been responsive, at all stages, to new information, to adopting new care processes and to developing new plans for our patients. This has applied across all professional groups, nursing, medical and AHPs, as well as our healthcare scientists. We have listened to front line staff and we’ve worked collaboratively across speciality groups, such as the North East London Critical Care Network and the London Respiratory Group. Some examples of the ways we have responded to this learning have included:

  • How we care for patients with acute respiratory illness. Historically, guidance has been to nurse patients on their stomach (proning) in intensive care when ventilated for acute lung injury. This has been extended to ‘awake’ patients with good effect
  • We recognised that there was an increased risk of developing blood clots, resulting in strokes and other complications in patients with Covid-19. This realisation led to a rapid change in guidelines on clot prevention treatment for our patients
  • Our Allied Health Care Professionals have developed an approach to rehabilitation of patients with Covid-19. This will progress as we see more patients with the effects of this significant illness

We have also participated in a number of national clinical trials looking at all aspects of Covid-19, from epidemiology to genomics to treatment interventions.

There has been an emerging generation of new leaders at all levels. Through the command structure, front line staff have been more empowered to escalate ideas and receive a response to them. Information has been shared with all staff on a daily basis by our communications team.

We need to prepare for what may happen next

We will be living with the impact of this pandemic for some time to come. We are hopeful that effective treatments will emerge as well as effective prevention, in the form of a vaccine. We await guidance and information on the understanding on antibody testing and future protection from this virus. We await the outcome of changes in policy regarding social distancing and return to work and to schools.

We need to prepare for how to manage emergency and urgent demand on our health services. The Royal College of Emergency Medicine has clearly stated that urgent pathways for care for patients need to be managed, in the future, in a very different way to reduce and avoid overcrowding in our emergency departments. We are keen to take part in London pilots that will look at how this care will be transformed.

We will need to continue with social distancing where possible at work and in other places. This will change how we teach, train and meet together.

We need to consider the vulnerable groups in our society and plan future health and care provision for this. As an acute Trust we need to play a greater role in this.

We also need to be agile and be prepared for future waves of this pandemic. The ambition is to ensure that we are able to care for all of our patients during future increases in Covid-19.

Quality of care

Patients that access our services whether they are in the community, hospital settings or via virtual clinics, need to be confident that they will receive consistent high-quality care which is provided by appropriately qualified and trained staff. The quality of care at BHRUT is underpinned by evidence-based practice and delivered using ratified policies and procedures that are reviewed in line with changes in practice.

Quality is monitored using a variety of indicators based on national, regional and local indicators and the Quality Assurance Committee, on behalf of the Board, review the outcomes. Outside of the organisation, the CQRM, run by our commissioners, holds the organisation to account for the delivery of these indicators. Each year, the organisation is inspected by the CQC which provides further external scrutiny and challenge.

During the Covid pandemic the pace of change was so great that, inevitably, a number of the quality indicators deteriorated for a short period of time. However, in recent weeks, there has been a re-focus and quality has demonstrably improved to previous levels. Monitoring will continue in line with previous requirements with a streamlined reporting structure being put in place.

In the coming months, it is imperative that the golden thread that weaves through any changes is quality and that we deliver effective and modern healthcare. As we move to the new BHRUT, all service changes need to include discussion and engagement with our patients and their families, and with our stakeholders, wherever possible. 

Workforce summary of the pandemic

This section seeks to capture the extent to which staff, systems and processes dramatically changed in order to meet the demands posed by the pandemic. Earlier sections have paid tribute to the extraordinary efforts, flexibility, and professionalism of the Trust’s workforce.  All of this was done while our staff faced very significant personal challenges affecting themselves, their family and their colleagues and friends. The scale and pace of these changes has meant that the needs of patients have been met. This was made possible by the existing strength of the Trust before the pandemic, together with the way that individual staff, teams and leaders stepped up to design and immediately deliver new ways of working and providing services, as the threat of the pandemic became a reality.

There is no simple way of describing what actually happened from the middle of March. This is because the threat of the pandemic literally affected every member of staff across two large hospitals, from procurement, to ward nursing, to occupational health, to security and to theatres. On the one hand, the new approach required the establishment of the central command and control, which the major incident protocol provides. The Gold and Silver commands were underpinned by an unprecedented level of Trust-wide coordination by brand new medical and nursing workforce planning hubs. This produced the rhythm of daily (and often more frequent) management, based on rapid and clear decision-making using multi-disciplinary working. The urgency of the tasks in hand did not allow time for committee-based decision-making, in the normal way. On the other hand, the new approach relied very heavily on local initiative, flexible teamwork, and inspiring leadership in order to galvanise available staff to provide new services in new ways. New local teams were established on the shop floor and within the corporate services.

The degree to which staff stepped up to meet the demands of the pandemic cannot be overstated. At the same time when the workforce capacity was severely reduced by increased sickness absence and self-isolating, more capacity and capability was needed. At its peak, more than 22% of our workforce was unable to work on-site due to illness and medical shielding. Substantial extra capacity was needed to provide Covid-19 related clinical services and extended support services such as procurement, estates and testing. This additional capacity was leveraged by staff transferring from areas no longer required and newly customised, dedicated training to upgrade skills.

Colleagues from across the Trust – medical staff, central recruitment teams, nursing leaders, line managers – have come together to deliver a comprehensive programme of work to address workforce matters. These programmes have included: recruitment, redeployment, returning staff, staff health and wellbeing and absence management. The Trust has employed a large number of third year nurse students and on-boarded a vast number of new healthcare assistants. The Trust now has a vacancy rate of 11%, with turnover down and a much-expanded Bank. The recruitment pipeline over the next few months is looking very healthy due to the recruitment activity undertaken over the past two months.

New ways of working have been road-tested on an industrial scale. In particular, enforced agile working, where staff could not work at the Trust or from their existing location, has seen the introduction of new processes which are far more efficient and effective than those which were no longer viable. For example, the electronic transfer of information, virtual meetings and interviews have built stronger teams, more integrated working and faster processes.

After a year of virtually no partnership working with our trade unions (because of a lengthy dispute) fresh energy, enthusiasm and real joint working is now taking place. Virtual working has enabled regular engagement, sharing of ideas and feedback between management and staff-side. We are working as equal participants in the endeavour to do the right thing for our staff and our patients. Alongside this, there has been an explosion of team huddles which staff have said have made them feel more engaged, better informed about what is going on, and instilled across our organisation a far greater sense of ‘team’.

A very alarming development, which the Trust has responded to head-on, is the evidence that our black, Asian and minority ethnic (BAME) communities are more prone to the worst outcome from Covid-19. The disproportionate death rate was first reported in mid-April at a national level. The Trust, with a workforce which is 50% BAME, acted swiftly to produce an urgent work programme to examine what is going on and to make sure that staff are getting risk assessments and the protection they need. This work has not yet concluded, and it will remain centre stage in terms of how our Trust is caring for its workforce.

Using the benefit of hindsight and driven by the need to start looking longer term, the Trust is listening to staff about what their views are of what happened. Of course, there is no single voice which represents the views of all the Trust’s workforce. However, there do appear to be some emerging common opinions about what has worked well and how the future could look to the benefit of patients and staff. No going back seems to resonate with staff who want recent changes to be continued and further reforms to be implemented. It is frequently said by staff from across the Trust - leaders and frontline employees alike - that there has been a positive transformation in how decisions are taken. Daily management has liberated managers and staff to get on with delivering change. Clarity of purpose, being empowered to get on with things, effective communications which are regular, transparent and informative, and real teamwork have all been seen to be fundamental to successful organisation, performance and practice.

What has changed? Everything has changed

In some ways, the pandemic response has put health and care transformation into fast forward. The BC world (before Covid-19) does seem a very long time ago and every part of the hospital and the system has changed. As we now move to AD (after disruption) it is critical that we are clear on learning as we move forward into a reset of the NHS. We must embed step changes that had proved stubborn or unobtainable before Covid-19.

Below are some high-level descriptors of what’s changed and how they will shape the way we are organised, do business and our future ways of working:

After Covid-19: what has changed?
Before Covid-19 (BC) After Disruption (AD)
Face-to-face appointments/clinical practice Virtual and digital by default
Managing waiting – retrospective Managing schedules - prospective
Organisation/divisional focus Integrated service line and care system focus
Layers of management Flatter structures
Systemic variation Highly reliable standard work
Focus on cost Focus on value and waste reduction
Focus on governance and assurance Focus on leadership
Frontline disempowered Empowered frontline; involvement in decision making; trust our people
Complex accountability Clear accountability
Operationally opaque Operational transparency
Hierarchy Team BHRUT
Focus on inputs Focus on outcomes
Disempowered patients Patients as providers
Siloed management Daily management
Disconnected corporate services Integrated corporate services
Micromanagement and templates Governing principles and collective leadership
Criteria led discharge Green – to – go
Focus on workforce cost Focus on workforce value

Governing principles

The Trust is now in a position where it needs to prepare for the next phase of the pandemic and implement changes to meet new demands. The Trust needs to act swiftly, but not at the expense of our values. In order to make sure that the right decisions are taken in the right way, involving the right people, a new approach has been developed which will guarantee that meeting the needs of our patients, staff and the wider community are centre stage. This new approach is built upon the learning and experience of the past few months by establishing a set of governing principles against which the main programmes of work, and associated decisions, will be measured.

This approach involves a set of core governing principles and customised principal operating standards relevant to the programme of work (see the model below). In the first instance, this approach has been produced in order to guide the Trust on how to structure the future design and delivery of direct and supporting clinical services. The governing principles and principal operating standards will determine where these services will be delivered on at least an interim (probably long term) basis. Essentially this is about the location from where clinical services will be delivered – with or without the patient present in person – and the way the services will be delivered from the location. The rationale behind this approach is that by establishing the governing principles, and the principal operating standards which flow from these, the right decisions will be taken in the best interests of patients, staff and the wider local community.

The governing principles apply to the set of decisions which need to be taken with regard to service provision. These principles flow from the Trust’s vision, mission, PRIDE Values and strategic intent – which are set out in The PRIDE Way triangle. Clearly, this exercise has been necessary given the extraordinary events caused by the pandemic and special demands which exist on the future delivery of clinical services. Prior to moving to decisions about each clinical service, a few keystone decisions need to be taken, as this will determine the range of options which are then available. At this stage, the model suggests the questions which need to be answered to establish what the rate-limiting decisions are which need to be taken initially. It might not be possible to meet each and every principal operating standard across all of the Trust’s service provision, although the governing principles do all need to be fully considered and applied.

Governing Principles

  • Highest quality of patient care and outcomes
  • Highest patient safety standards
  • Equality, diversity and inclusion
  • Highest visitor safety standards
  • Guaranteed staff health and safety
  • Optimum level of service suppply to meet demand
  • Guaranteed Covid-19 and general infection control
  • Staff health and welbeing support
  • Working practice changes subject to Trust policy and procedures
  • Staff engagement and satisfaction
  • Acceptable level of risk
  • Optimum use of the hospitals' estate and community-based facilities
  • Minimise waste and unwarranted variation

Principal Operating Standards

  • Genuine consultation and engagement with those leading and providing clinical services
  • Effective multi-disciplinary working
  • Patient discharge once clinically-fit  to do so
  • Scheduled care with no waiting
  • Proven performance from recent service changes
  • Managed movement around the hospitals' estate by staff, patients, visitors and contractors
  • Affordable in terms of revenue and capital
  • Compatible with the extent of the hospitals' estate flexibility of use
  • Up to seven day service provision
  • Responsive to patient needs and adaptable

Initial Keystone Decisions

  • To what extent can the hospitals' estate be divided between blue, yellow and green areas?
  • What does national guidance prescribe (limits and opportunities) with regard to the future provision of clinical services?
  • Which major capital items are fixed or can be moved to another place?
  • How much time is available to design and then implement the necessary changes to deliver services in time?

High level work programme

Running highly reliable hospitals

We will test with staff and patients if our current vision is the one to carry us forward. Our priority has to be a focus on high reliability and reducing variation in all its forms and a focus on operational and clinical excellence. We have learned in recent months that daily management, ‘delayering’ management responsibilities and instilling a clearer accountability framework has reduced duplication and delivered higher reliability. We will lock this in.

The principles of infection prevention and control in the context of Covid-19 mean patients will receive care in our hospitals in a fundamentally different way, to reduce the risk to patients attending for planned and emergency care. This also creates an opportunity to provide better care for all. As part of this we will re-imagine how we deliver care and the use of space. This includes improving capacity and capability at both hospitals (recognising the Covid-19 infection control standards), delivering an outstanding care model that offers effective triage, an excellent emergency village and clear routes to onwards care. We will also increase focus on to improve reliability with a care model that improves mobility, independence and outcomes. This will be delivered as part of the North East London (NEL) Elective Services Alliance ensuring standardisation and optimisation of the NHS safe ‘Green’ Covid-19 protected capacity. We will continue to deliver high quality whilst working closely with system partners. On cancer, we will build on the good service we already provide and as a full partner in NEL Cancer Alliance coordinating the access to the most specialist treatment for those that need itWe will provide care in the right place, at the right time, by configuring services appropriately at our two main sites as well as offering more care virtually and in the community. In doing this we will improve outcomes and experience for our patients as well as our staff.

Getting back on track with elective services is not an easy ask, especially as we are planning to continue a full elective programme through any future peaks in Covid-19 demand. We have modelled the elective care backlog (accumulated pre – and – during Phase One Covid-19) and our business as usual demand; we have also modelled NHS available Covid-19 protected elective capacity and there is a significant gap. We will require elective capacity from independent sector hospitals and the NEL ISTC for a minimum of 12 months.

This analysis assumes there is a 20% reduction of non-elective non-Covid bed days due to improvements to the discharge model and admissions avoidance (a result of improved front door care models). This is currently applied consistently across both sites, but we recognise that the opportunity will be based on the population demographics and maturity/variation in clinical models prior to transformational changes implemented over recent months.

Partnerships with purpose

Accelerating ‘Integrated Provider’ borough-based partnerships

We are at the foothills of system working and plan to develop more meaningful working relationships with our BHR system partners in primary care; in the three local authorities; and with NELFT. We have a role to play to work differently together – with all our stakeholders - to improve health, reduce inequalities in outcomes and meet the varying physical and mental health needs of our population. We will work with partners to produce a holistic strategy for population health management in the coming months, which will have an emphasis on starting well, living well and ageing well. Building on the foundations that already exist, we will begin transforming services by focusing our effort on providing frailty care to support care at home and in care homes, supporting people to live in good health for longer with the input of excellent multidisciplinary teams. One component of this is ensuring we deliver activity in the right place, and support people to retain their independence, rather than hospital being the default setting of care. Over the coming years, we must work together to ensure more of our collective resources are used to support people in communities as opposed to in a hospital bed. To do so will mean more years in good health and address the uncoordinated provision currently on offer, but it will also mean we can respond effectively to the growth of our population.

The Government’s spending has secured, in the short term, income for citizens and vital infrastructure and services. “Protect our NHS” was at the heart of the Government’s message with front line staff responding superbly and being held in reverence – demonstrated by weekly applause across the nation. The backdrop of an emerging economic crisis, requirements for greater productivity and agility will require the NHS to play its crucial role as a corporate citizen across BHR and beyond.

North East London Health and Care Partnership

As some aspects of healthcare become increasingly specialist, we must work with our NEL partners to ensure we are giving all our patients access to the care they need, by delivering pathways across organisational boundaries. In the NEL ICS we are planning for the devolution of specialised commissioning and have created an acute collaboration involving Barts Health NHS Trust, Homerton University Hospital NHS Foundation Trust and BHRUT to develop the NEL-wide acute strategy. Where we are the provider of specialist, low frequency services we need to do this in a joined-up way for the benefit of the wider NEL population. This includes creating managed clinical networks with other providers for neurosurgery, stroke, vascular, NICU and maternity services. Clinical support services such as pathology, radiology, pharmacy, and corporate services are also changing significantly through new technologies. This is creating new opportunities to collaborate on their delivery, consolidating those benefitting from scale at a NEL level; standardising others across NEL; and localising the remainder. We will support research and innovation at our hospital sites with academic partners and will provide even better care models as a result of working strongly in partnership with other organisations. All of this will allow us to contribute as a leading partner to a refreshed clinical strategy for NEL, building on the response submitted last year to the NHS Long Term Plan, as well delivering our part of the NHS’s vision for London. 

Happy Hospitals

The sense of camaraderie and the ‘all in it together mentality’ through these difficult and challenging times has seen the real development of Team BHRUT. This has built upon the ‘green shoots’ which our annual staff survey reported on in early 2020. Staff support and wellbeing has been a critical focus from all leaders and a compassionate leadership style has developed. A priority of the Executive has been to empower and trust the front-line decision makers. Our staff do not want to return to the way it was. We should aspire to be the NHS’s happiest hospitals. Staff happiness and organisational success are inextricably linked, and our success is measured by the care our patients receive. Organisations that truly support the wellbeing and morale of their staff provide better patient care and outcomes, attract and retain talented people, and are more efficient with their resources. It would also be the fulfilment of our commitment to equality, diversity and inclusion.

As an organisation, we aspire to be a place where anyone working at BHRUT will be happy and healthy – truly developing ‘Happy Hospitals’. Our objective is to develop a consistent working environment which enables our staff to be happy and healthy; using the learning from Covid-19 as a platform to break the ‘historical culture’ mould.

The table below outlines what environment gets the best out of staff working at BHRUT, based on our previous diagnostic

The environment that gets the best out of staff working at BHRUT
I am treated with respect and feel included, the opposite is not tolerated I have role clarity, achievable goals and a purpose which connects me to patients and others I am rewarded and supported to develop my skills, my career and staying healthy
I work as part of a multi-skilled real team and we are empowered to make improvements, working across teams I feel psychologically safe to speak up, try something and learn without fear of blame or retribution I know how to get things done at pace, supported by clear and simple processes and technology
 
I am enabled and supported by a leader who behaves with compassion. They meaningfully communicate with me, remove my barriers, develop me, hold me to my responsibilities and have my happiness and health as their top priority

As the experience of Covid-19 has shown, we have the potential to develop this culture. We now need to be focused on how we embed the best from this experience into the future ‘new normal’ culture.

This starts through setting out our ‘Happy Hospitals’ manifesto, alongside re-setting the vision, mission and goals of the organisation. This manifesto will set out the elements of our new culture post Covid-19 and guide us in how we develop the working environment. We will conduct a cultural barometer to develop this manifesto with our staff, our trade unions and our patients. It will be achieved at pace through holding conversations and surveys to gain a new cultural baseline.

There will be a programme of work to support the development and embedding of the manifesto. Foundational elements of the manifesto will include:

  • Resetting the culture and role of the leader through our happiness manifesto (our cultural standard)
  • Respect for people behaviours (how we treat each other)
  • Wellbeing and wellness (how we support our health)
  • Organisation design and talent management (how we are structured and developed for the future) will need to be looked at.

Finance

We need to ensure we are far more focused on the best patient outcomes and experience at minimal waste and on value for money from capital investments. We need to devote less time to detailed scorekeeping and budget reconciliations.

Our approach

Design:

Ensure high quality finance input into major design as part of an integrated management team across the key clinical areas, leading to evidence based and compelling cases for change.

  • Ensure efficient workforce models and non-pay consequences, minimising excess cost of agency (£10m+ waste) and optimising utilisation and productivity (£20m+)
  • This approach will also support the approval process for capital.

Delivery:

Replace the 500 budget cost centres with rounded performance management scorecards across quality, performance, workforce, money and system for each of the top 50 or so management units – essentially a zero-based approach to being clear on outcomes and value.

Organisation:

We want to move to an organisation where customer facing roles such as finance business partners are closer to clinical and operational leaders, and other roles such as transaction processing are part of an integrated collaboration with NEL.

Business intelligence

We are updating our business intelligence strategy with NEL in parallel with our digital strategy. In concept, we need actionable intelligence as shown below:

Actionable intelligence
Design: Decision support Evidence rich case for change
Delivery: Performance management Insight and prediction

An example of the design category is a capital investment case for a new, improved paediatric service which will want to focus on patient outcomes and experiences, highly reliable performance, sustainable, happy workforce, minimal financial waste and integrated system pathways. This will need good evidence and so good intelligence.

A good example of a succinct performance management dashboard is the weather forecast, or a moving map on a plane - where are we, where are we going and when will we get there.   

Some key next steps

Review Mission and Vision statements and PRIDE Way triangle

An important component of our continuous improvement PRIDE Way approach is our triangle. In line with our determination not to go back, it would make good sense to review the PRIDE Way triangle. It is also a good time to sense check our Vision and Mission statements to determine if they remain relevant in this new NHS and New BHRUT.

Review our operational and clinical leadership arrangements

Empowered and supported clinical leaders and leadership has always been important. Strong clinical voices at both the NEL and BHR levels is more important than ever. We will review our leadership and operational delivery structures to ensure highly reliable daily management is designed into hospital site-based delivery and highly effective cross site clinical leadership is ensured, with appropriate corporate support. This approach will drive the design and delivery of clinical services both for now and for the future.

Developing a highly reliable performance culture

We will develop an integrated performance framework that will sit alongside our operational and clinical delivery arrangements. This will be prospective and focus on forecasting and improvement rather than retrospective reporting. The emphasis will be on caring for our patients, caring for our staff and caring for our money.

Operational Goals for 2020/21 and beyond

We will finalise operational goals under the three programme headings:

  1. Highly reliable hospitals
    1. Respond to ongoing Covid-19 pandemic – minimising excess mortality and morbidity whilst maintaining as near normal elective programme in both Covid-19 peaks and troughs.
    2. Deliver a Good rating in the next CQC assessment and continue the journey towards Outstanding.
    3. Sustaining ED performance at >90% (all types) from Q3 onwards.
    4. Deliver an underlying monthly financial deficit run rate of £4m by March 2021
  1. Partnerships with purpose
    1. Align our clinical leadership to BHR ambitions re: Starting Well, Keeping Well and Ageing Well.
    2. Design and Implement a BHR sector wide service in support of out-of-hospital care for people with increasing frailty.
    3. BHRUT to lead NEL Elective Care reform programme.  This will include being a lead provider for at least two high volume/low acuity specialties.
  1. Happy Hospitals
    1. To see continued improvement on the Equality, Diversity and Inclusion (EDI) score from 8.5 to 8.7. We will progress our plans for Inspire 3 (our positive action BAME development programme) and ensure the BAME voice is heard by our Senior Leaders and Trust Board. Our three inclusion networks will be central to deciding and planning our work over the year and they will help co-design our plans.
    2. To improve our staff survey, return rate from 57% to 60%. We also want to see continued improvement in a key indicator of recommending BHRUT as a place to work from 57% to 60%. By encompassing the new ways of working during the Covid-19 period ensure compassionate leadership continues along with improvements in our culture.
    3. Improved retention indicators with turnover reducing to 10 % and vacancy rates reducing to 9% over the year.

Estates strategy

Estates need to provide safe, segregated theatre and bed capacity to meet London’s first three tests in the near term, and demographic demand in the longer term.

NHS London first three tests:

  1. How do we retain resilience to deal with on-going Covid-19 and pandemic needs?
  2. How do we do everything we can to minimise excess mortality and morbidity from non-Covid-19 causes?
  3. How do we return to the right level of access performance for elective cases prioritised by clinical need?

Digital strategy

We have a current digital programme, which is already challenging; this will now need to be updated across NEL for infrastructure (one platform); applications (ours is maximising benefit from core Medway integration); and, crucially, business intelligence. We need to create a data / evidence driven environment led by patient outcomes and experience – both across our strategic change agenda and the daily control and improvement processes.

Tony Chambers
Chief Executive
June 2020