Dr Jeremy Rushmer, interim Medical Director at North Cumbria NHS Trust

In an open and thought provoking interview with FMLM, Dr Jeremy Rushmer, interim Medical Director at North Cumbria University Hospitals NHS Trust, one of the 14 Trusts reviewed in the Keogh report, talks about the process and next steps from a trust’s perspective.

The Keogh review identified a broad cross-section of factors that contributed to the quality of care issues at North Cumbria. Overall, do you view the way this review was conducted and its findings to be fair and reasonable?

Yes, the findings of the Keogh review were broadly similar to the findings of our own existing process of due diligence so there were no major issues in the review that came as a surprise to either staff or management. We were already aware that we were poorly performing and had already started a journey of improvement, as Sir Bruce acknowledged in his report, but the impact of this review has given our proceedings a sense of urgency. 

As the medical director brought in to help resolve these issues, what do you think were the main external pressures on the trust, and/or failings within the trust, that led to this decline in standards?

I think it’s important to note that the issues identified in the Keogh review did not appear overnight and there is no ‘quick-fix’ solution to problems that have arisen from multiple complex factors over the course of several years.

For example, it is no secret that North Cumbria has been subject to financial pressures for several years and there are plans for it soon to be acquired by Northumbria Healthcare NHS Foundation Trust. Our staff have already had to adjust to a series of different management systems that have come and gone in quick succession, keep up with the upheaval of the health and social care arrangements more broadly while all the time continuing with their day to day responsibility of treating patients and serving the community as best as possible. This has all contributed to a challenging working environment.

But fundamentally, I think the root of most of the problems we are trying to tackle lies in the trust’s rural and intellectual isolation. Sir Bruce himself said ‘no hospital is an island’ but without the benefit of strong connections to other healthcare providers and agencies and no other major trusts nearby to generate a competitive environment, that is exactly the situation North Cumbria has found itself in.

This isolation has affected our capacity and capability because it is difficult to recruit and retain good staff. We have had no choice but to rely on locum staff who come and go, so one of our major challenges is to identify what we need to do to convince the best people to stay. And this goes far beyond the straightforward changes we could make to facilities and equipment; good people don’t decide to move on simply because the paintwork isn’t right.

The combination of this isolation and a weak relationship between clinicians on the wards and management resulted in a lack of external stimulation to bring about change or any motivation for staff themselves to drive culture change forward. When I first took on this role my impression was that staff had become boxed in, defensive and threatened by the thought of change. The approach to problem-solving and quality improvement had become far too focussed on technical aspects and a common response to any culture-related issue was that the ‘acquisition will fix it’. So there was little incentive for clinicians and departments to take ownership of issues and little expectation for them to do so.

Where does a medical director start when faced with such a complex set of challenges?

One of the first things to do is to recognise that one person alone cannot bring about long-term change and nor should only one person bear the responsibility. An effective leader needs to identify allies across the senior management team and at senior nursing and consultant level who buy into your change agenda. At North Cumbria, my priority is to identify those who can help me establish ‘safety and quality’ as the watchwords for everything we do and everything that needs to change.

It became clear from the start that there were pockets of clinicians who were extremely frustrated at the slow pace of change and were keen to share ideas and engage more fully with the process so they were the first to come on board.

But it isn’t enough to find good people with good ideas, leaders need to give these allies the time, space and environment to develop their own leadership skills so they have the confidence and ability to get their teams behind them and bring their ideas to fruition.

Achieving positive long-term change is entirely dependent on the doctors, nurses and other team members at the ward level backing the change and taking responsibility to implement it themselves, which requires a ‘top-down and bottom-up’ approach from leaders. This means leaders have to cultivate an open, honest and transparent system of communication between themselves, clinical leaders and all staff to ensure everyone has the opportunity and the courage to speak up when things go wrong and share ideas about how to put them right. Those on the ‘shop floor’ are the only ones who can truly implement change so they have to be empowered and supported to take action.

With this in mind, I expect all clinicians and their teams to take responsibility for every aspect of their service all the time, regardless of what acquisition or other trust-wide changes may be taking place. This extends beyond the quality of clinical care they provide to include financial management, governance, safety, outcomes, compliance, and the reporting procedures and learning opportunities from serious incidents.