The Mid Staffordshire NHS Foundation Trust has been placed under administration by Monitor, the NHS economic regulator.

A report for Monitor said the Trust was “unsustainable” and recommended closing down its maternity, A&E and intensive care units.

The first Foundation Trust to go into administration, Mid Staffs will be run for the next 145 days by two analysts from Ernst & Young before it is reconfigured.

The report stated that the services it recommended for closure could be provided at hospitals in North Staffordshire, Wolverhampton and Walsall.

While Monitor said the Francis report was not the reason for its decision, it warned that Mid Staffs was “neither clinically nor financially sustainable”.

Mid Staffs received a £20m bailout in 2012, pending the Francis report’s publication. The report, which listed the Trust’s failures during four years in which over 400 patients died through neglect, did not inspire confidence in its future.

The administrators will seek to work with local commissioners and other healthcare organisations to produce a long-term plan for service delivery. Current services will continue during the 145-day administration period.

A local campaign group, Support Stafford, has called the plans for shutting down acute services in Stafford “unacceptable”.

Jeremy Lefroy, Conservative MP for Stafford, commented: “There is a vital need to retain acute services in Stafford and Cannock because the capacity elsewhere is simply not there.

“They also need to consider the huge disadvantage to local people who would have to travel much longer distances for their treatment, but also for hospital visitors who would have to do the same.”

The first criminal investigation into a death at Stafford General Hospital has found that a patient with a broken hip died as a result of not being given insulin.

Gillian Astbury, aged 66, died in 2007 in a diabetic coma after a new nursing team failed to read her clinical notes.

The Health and Safety Executive (HSE) is investigating the death as a possible criminal violation of the Health and Safety at Work Act, punishable by a fine.

This is the first criminal investigation arising from the Mid-Staffs tragedy, and the first instance of failure to give medication being considered as a crime.

Ms Astbury was admitted to Stafford General Hospital in 2007 with hip and arm fractures following a fall. Her partner reported finding her left without food or cleaning on several occasions.

The inquest jury concluded: “Nursing facilities were poor, staff levels were too low, training was poor, and record keeping and communications systems were poor and inadequately managed.”

The Francis inquiry said the Mid-Staffordshire NHS Foundation Trust had put “corporate self-interest and cost control ahead of quality and patient safety”.

However, NHS Chief Executive Sir David Nicholson blamed the deaths on the Labour Government’s infection control and waiting time targets, which he said monopolised clinical attention in hospitals.

The HSE commented that it will focus on “establishing whether there is evidence of the employer or individuals failing to comply with their responsibilities under the Health and Safety at Work Act.”

The case could have implications for many situations in which healthcare professionals administer medication.

The new NHS structure came into force on 1 April, with local commissioning now entrusted to clinical commissioning groups (CCGs) that combine business and clinical expertise.

The CCGs are managed by NHS England (formerly the NHS Commissioning Board) and governed by new laws that enforce a ‘level playing field’ for provider competition.

The 152 Primary Care Trusts are now abolished, and all NHS hospital trusts are required to qualify for Foundation Trust status within the next year.

NICE, renamed the National Institute for Health and Care Excellence, will set standards for both health and social care services, promoting integrated care.

The statutory role of CCGs in facilitating competition between providers of NHS services has polarised opinion, with only a third of GPs in a Pulse survey saying they felt empowered by the new system.

According to private health analysts Laing and Buisson, the NHS in England spent 11% more on services from private providers in 2012 than in 2011 – a clear sign that the provider base is already shifting.

Professor David Haslam, the new Chairman of NICE, commented: “It is a time of huge risk. We know in medical care in hospital that the greatest risk is when patients are being handed over from one person to another. It is a risky time for the system, so it is important that the big players work together.”

Mike Farrar (pictured), Chief Executive of the NHS Confederation and a long-time champion of community-based healthcare, warned that trying to improve patient safety while reducing costs would place great pressure on the new NHS.

“We need to recognise the huge challenges facing the health service,” he said. “New structures alone won’t enable us to tackle these challenges, and we should not see them as a silver bullet.”

Monitor has placed Mid Staffordshire Foundation Trust under administration, saying it cannot be sustained in its current form.

The combination of the trust’s current financial difficulties and the impact of the Francis report has proved impossible to surmount.

Monitor will appoint special administrators to run Mid Staffs and plan its reorganisation – with options including the dissolution of the trust.

Mid Staffs is the second Foundation Trust to be placed under administration this year: the first, South London, was judged to have failed financially but not clinically, with PFI debts being a major factor.

Mid Staffs is also facing financial problems, having been bailed out with £20m from the DH in 2012, and having to cut its costs by 7% this year. Its small size – only two acute hospitals – counts against it economically.

However, it is also under pressure not to let its clinical standards slip, following the Francis report into over 400 preventable deaths at Stafford Hospital from 2004 to 2008.

The growing panic in the trust was exposed when a Stafford Hospital paramedic abused health campaigner Julie Bailey on Twitter, saying that he hoped she became seriously ill and found the nearest hospital shut down.

Julie Bailey’s ‘Cure the NHS’ campaign is credited with having led to the Mid Staffs enquiry. Her mother was among the people who died due to serious medical neglect at Stafford Hospital.

Monitor sent a ‘contingency planning team’ into Mid Staffs five months ago. Its report into “sustainable options for alternative clinical models in the area” will shortly be published, the regulator said.

The special administrators will have 150 days to develop a plan for service reconfiguration, working with local commissioners.

Professor John Caldwell, Chairman of Mid Staffordshire FT, said: “We have accepted for some time that MSFT working alone cannot produce a long lasting solution to the issues we face to ensure financial and clinical sustainability.”

Given that the financial constraints of FT status previously led the trust to experience a disastrous breakdown of care, finding a solution there is a key challenge for the NHS reform programme.

The ABPI sets out to deliver tailored support and advice to healthcare providers on the medicines its member companies produce. Kevin Blakemore, NHS Partnerships Manager at the Association of the British Pharmaceutical Industry, discusses the advantage of partnerships in healthcare.

The pharmaceutical industry has experienced tremendous change and, as part of that evolution, forming successful partnerships in healthcare has become integral to our way of working. The NHS delivers outstanding care to patients – utilising the innovative medicines the pharmaceutical industry produces – so it makes perfect sense for us to work together, ensuring the best possible outcomes for patients. There are some points, however, to consider when embarking on ‘joint working’ ventures – these partnerships must be managed and guided to ensure that the process is efficient, seamless and offers patients maximum benefit.

Often these partnerships can result in patients spending less time in secondary care settings, and can deliver significant savings. Patients benefit most when those with a stake in their care work effectively, enthusiastically and efficiently together.

Joint working describes situations where, for the benefit of patients, NHS and industry, organisations pool skills, experiences and resources for the joint development and implementation of patient centred projects and a shared commitment to creating a streamlined, joined-up care pathway, where patients are kept at the heart.

Flexible joints
Joint working has already benefited thousands of patients across the UK and to help achieve greater outcomes, the Association of the British Pharmaceutical Industry (ABPI) has developed the ‘NHS Partnerships Team’. My dedicated team work with healthcare providers up and down the country, providing specialist advice and support, while facilitating successful working relationships.

The NHS Partnerships team is made up of eight individuals, each responsible for a different area of England. Their knowledge and expertise includes experience of working within the pharmaceutical industry and the NHS. They also bring their knowledge of innovative and effective medicines created by the industry, and this can be utilised for the benefit of patients. The central focus of the team is improving the healthcare environment in order to increase access to and uptake of innovative products. The team consists of Diana Vegh, Karen Thomas, Carol Blount, Harriet Lewis, Andy Riley, Mike Ringe, Angela Logun and myself.

Diana Vegh started her career in the pharmaceutical industry within regulatory affairs in AstraZeneca, working in scientific roles of increasing seniority. She then moved to the NHS where she held senior positions in the Strategic Health Authority, two PCTs and a Foundation Trust in the South West.
Diana returned to industry in a commercial capacity at UCB Pharma, working in market access for products. She has extensive networks across the industry and the NHS, and a wealth of practical, positive experience.

Veteran’s parade
Karen Thomas – a recent addition to the NHS Partnerships Team – has extensive experience of working in the pharmaceutical industry, and for the past 12 years Karen has worked for Bristol Myers Squibb, where her roles spanned finances, sales, commercial and market access, covering several therapeutic disease areas. Karen joined the ABPI in November 2012 as the Regional Partnership Manager for London.

Harriet Lewis has been a pharmacist for over 20 years. She has worked in a wide range of healthcare sectors including industry, community, hospital and primary care. Before joining the ABPI, Harriet’s most recent role was Associate Director for Medicines Advice with the National Institute for Health and Clinical Excellence (NICE). Harriet has led on a number of NHS support programmes, including local formularies, local decision making, controlled drugs, accountable officers and ‘specials’. She has authored several key documents for NPC and NICE. Harriet is the Regional Partnership Manager for the North.

Most recent additions to the team are Andy Riley and Mike Ringe. Andy joins us as the ABPI Regional NHS Partnership Manager for Midlands and East. He qualified as a pharmacist in 1987 and has held posts in hospitals, community pharmacies and health authorities in London, the North West and the West Midlands. Mike joins us as the ABPI Group Therapy Manager directly from the NHS, and previously held the position of Chief Operating Officer at Luton Clinical Commissioning Group.

My role is the NHS Partnerships Manager and I manage the team. Previously, I have worked in the pharmaceutical industry for over 25 years – at UCB and GlaxoSmithKline (GSK) – and I have been responsible for developing national level methodologies and frameworks to support patient and market access programmes.

Bonded by blood
The ABPI recently undertook a joint working project at a hospital trust in the North of England looking at epistaxis – one of the most common ENT emergencies in England, with over 27,000 patients presented to secondary care between 2008 and 2011. In 2009/10 the trust admitted 250 patients presenting the condition, with the average length of stay at over two days, costing a minimum of £400 per patient per day.

Like many other hospitals, the trust had limited specialist ENT experience in their emergency departments, and as a consequence nasal packing was frequently used as a first line treatment – even for small volume bleeding – when a more conservative or targeted approach would have been safe and effective. There was a clear opportunity here for the patient pathway to be revised and a different approach taken.

Through the ABPI, a joint working project was instigated between a local pharmaceutical company and the trust. They jointly agreed – through a joint working agreement – to truly address the challenges within the current treatment regime and completely redesign the service. Consequently, it addressed the training requirements within A&E and junior doctors.

The new treatment pathway encouraged clinicians to identify the bleeding point, if possible, and in cases of continued bleeding, to consider the use of a product manufactured by the local company – thereby avoiding unnecessary hospital admissions. The company and trust continued to work in partnership to develop training materials in order to develop the new treatment pathway and introduce the use of the medicine where possible.

This venture resulted in a number of positive outcomes, which included a reduction in hospital stays, improving productivity and cost savings. But most importantly, when compared with the three preceding years, the audit of the venture showed that the total number of bed days due to epistaxis, was reduced by 30 per cent and length of stay was reduced by 21 per cent. Additionally, staff were motivated to consider an alternative to immediate nasal packing/admission, which also resulted in a reduction in the length of stay.

QIPP while ahead
Working with the Department of Health and the NHS, we have developed a toolkit on successful joint working. Joint working is a relatively new concept for many, but has already shown tangible benefits to patients, the NHS and industry. For example:

East Lincolnshire Primary Care Trust (PCT) reduced hospital admissions for Chronic Obstructive Pulmonary Disease (COPD) by 23%, through working with three companies to target and screen patients, train clinicians and set up specific COPD clinics.

In Ashton Leigh and Wigan the PCT is tackling low life expectancy, high rates of heart disease and diabetes by working with industry on a ‘Find and Treat’ strategy.

The innovative approach to patient care adopted by that trust was aligned with the Quality, Innovation, Productivity and Prevention (QIPP) programme. QIPP is an NHS initiative to improve the quality of care it delivers, while at the same time making savings that can be reinvested into the service. It engages with staff from across the NHS, at local and regional level, and is supported by QIPP plans and work streams that provide guidance and tools.

The NHS also works with a range of partners to deliver QIPP, one of which is the pharmaceutical industry. Apart from supplying medicines that improve the quality of patients’ lives and outcomes, the industry can contribute business skills and expertise, as well as extensive knowledge of the therapy areas relevant to its medicines.

Joint working is the foundation for creating, developing and implementing innovative healthcare solutions which can lead to better health outcomes. We believe this is the way forward in healthcare and both the NHS and industry must seek out more opportunities to work together.

Is QIPP really about ‘doing more with less’?

The NHS Quality, Innovation, Productivity and Prevention (QIPP) Challenge was launched in March 2010 as a strategy to facilitate major cost savings within the NHS, in response to the impact of the global recession. The principle of QIPP was that given the need for austerity budgeting, serious planning and rethinking were needed to ensure ‘smart’ cost-cutting that did not harm patient outcomes. The QIPP agenda was about identifying solutions that held together the four key principles, reducing overall costs by making interventions more timely, efficient and effective.

The new Government’s NHS reforms promised to facilitate QIPP by empowering local providers and commissioners to develop the best solutions for their communities. However, the economic pressures on CCGs and Foundation Trusts within the new system, combined with the ‘Nicholson challenge’ of cutting £5 billion out of the NHS budget in each of four successive years, have meant that the dominant theme of QIPP at a local level is cost reduction.

The first full year of QIPP (2011–12) delivered savings of £5.8 billion against a target of $5 billion. However, reports of NHS rationing and ‘postcode prescribing’ have proliferated. QIPP was devised as a strategy to combine two goals: the shift towards community-based healthcare and the urgent drive towards NHS cost-cutting. Is that still the agenda, or have the pressures of NHS reform reduced its four principles to one: reducing expenditure? Is QIPP really about “doing more with less”, as Andrew Lansley claimed, or is it just about doing with less?

A new healthcare paradigm
The DH booklet introducing the QIPP challenge in March 2010 set the context: “The NHS needs to identify £15–20 billion of efficiency savings by the end of 2013/14 that can be reinvested in the service to continue to deliver year on year quality improvements.” The booklet placed emphasis on improving quality while reducing overall costs through strategies such as early intervention, improved infection control and home-based care. Its authors included Jim Easton, then National Director for Improvement and Efficiency. The DH described a series of QIPP ‘workstreams’ it was setting up to help clinical teams and NHS organisations “improve quality and productivity across care pathways”. The first of these related to care of long-term conditions, urgent care and end-of-life care. Further workstreams would examine safety challenges, such as pressure ulcers (bedsores), and ‘right care’ issues such as referral management and identifying “low-value treatments” (later to become controversial issues).

The authors called for “a collective response at local, regional and national level” to address the QIPP priorities. These included early diagnosis, primary and secondary prevention and patient self-management. The need for “better partnerships between primary, community and secondary care to support people with long-term conditions” was emphasised. QIPP extended from the “daily clinical practice” of individual HCPs to “the wider care pathway”, the booklet said. Each SHA had its own QIPP lead and innovation lead, and was establishing an online regional ‘quality observatory’ and Innovation Fund to help clinical teams improve quality and productivity.

These ideas were illustrated by case studies where local NHS organisations had developed better and more affordable healthcare solutions. These included the use of an electronic system to ‘re-engineer’ blood transfusion, reducing waste and improving safety; and systematic guidance on antibiotic prescribing to reduce rates of C. difficile infection. These solutions all involved using teamwork and sharing information to make the best use of available resources.

The booklet ended on a warning note: “If we do not respond to this challenge there is a real risk that the need to cut costs will overtake our best intentions to improve care for our patients.” More than two years later, the crucial question is: has QIPP averted that outcome or brought it closer?

Innovation is ‘core activity’
In June 2012, Nicholson’s annual report claimed 2011/12 had been “a remarkable year” for the NHS. He highlighted the contribution of local initiatives to maintaining service quality while cutting costs. Austerity would dominate the NHS “for the foreseeable future”, he said. However, the innovation agenda promoted by the previous Government’s Office for Life Science and revived by the current Government in December 2011 would engage dynamically with that challenge: “Innovation has to... become the core activity of the NHS.”

His report went through the elements of QIPP, noting achievements in each area. Quality achievements highlighted included: in cancer care, the achievement of key treatment standards across all eight performance measures, as well as improved early detection figures; and in stroke care, better access to specialist stroke units and faster treatment of people with transient ischaemic attacks. Community-based asthma services in South East Essex were used as an example of a successful local initiative.

The brief section on innovation focused largely on the use of technologies in the community, including telehealth and home dialysis. The preventative care section emphasised the growing role of health visitors, and drew attention to the success of a national screening campaign for risk of venous thromboembolism (VTE) with prophylactic drug treatment given where needed.

In the productivity section, Nicholson noted QIPP savings of £5.8bn and praised the “modest reduction in activity levels” across the NHS – placing these in the context of the QIPP Long-term Condition Workstream, which aims to reduce unscheduled hospital admissions by 20%, reduce hospital stay length by 25%, and maximise the role of “supported care planning” in helping people to manage their own health. However, no reference was made to the rationing of procedures or the cuts in hospital nurse staffing.

Milestones or millstones?
A recent Health Service Journal report on the DH’s QIPP tracker indicates that the PCTs (soon to be abolished) plan savings worth £13bn nationwide between now and 2015, with £4.5bn of this to be achieved through the 53 local QIPP plans. The planned savings are front-loaded: £3.8bn this year and £3.6bn, £2.9bn and £2.6bn in the next three years. However, only £2bn of the planned QIPP savings are currently being achieved on schedule, and only six local QIPP plans are on track with all of their workstreams.

According to the tracker, productivity gains are the main objective of most local initiatives. Common features include the redesign of care pathways for long-term conditions, including diabetes and COPD, and the development of integrated care teams for dementia patients. However, many local plans have the single goal of reducing the cost of services – for example, South of Tyne and Wear PCT notes as an objective: “reduce price paid for Gateshead Health Foundation Trust older people’s mental health service”.

John Appleby, chief economist of the King’s Fund, commented that this emphasis on savings denied the original point of QIPP: “to improve value to patients”. He also said there was no evidence of the money saved being reinvested in future services, which was a key principle of the original QIPP agenda. The Audit Commission has since reported that the NHS has £4bn in “uncommitted finances”: cash reserves created by aggressive cost-cutting. Mike Farrar, Chief Executive of the NHS Confederation, has argued that this money needs to be invested in community and primary care.

Jim Easton, the NHS Commissioning Board’s Director of Improvement and Transformation, warned in July that too many NHS organisations were relying on spending cuts without any element of service redesign. The “deeper change” of shifting healthcare to the community was not being undertaken, he said, and
QIPP was becoming a “label” for “cost improvement plans”. As a result, the QIPP savings of the past year would be very difficult to repeat. Instead of building a new healthcare model, the NHS was just cutting
parts of the old one.

Easton has since announced that the Board will fund a new innovation body to deliver a “system-wide” response to the QIPP challenge. From April 2013, the new organisation will replace all existing NHS innovation and technology adoption bodies. He anticipates that it will “provide hands-on support for great models of care” developed within and beyond the healthcare sector. However, his resignation has cast a shadow over these plans.

According to the King’s Fund, 27 of 42 NHS finance directors it surveyed believe there is a high risk that the NHS will fail to meet the ‘Nicholson challenge’. A key question for industry, and for patients, is whether QIPP can help the NHS deliver on the more important challenge of transforming healthcare to meet the
changing needs of the population.

Monitor has found Sherwood Forest Hospitals Foundation Trust in Nottinghamshire to be in significant breach of its terms of authorisation, due to mounting PFI debts.

The economic regulator said the trust had “failed to deliver recurrent savings of £10m in the last financial year and made a £5.9m loss in quarter one this year”.

Sherwood Forest Hospitals currently spends 17% of its income on PFI costs, which are escalating at £1.5m per year.

Monitor Chief Executive David Bennett said Sherwood Forest is one of two foundation trusts whose “underlying” financial problems are due to PFI contracts.

The trust spent £42.5m on PFI costs last year.

Monitor commented: “The trust’s PFI unitary charge is rising annually as a percentage of income, and when combined with falling revenue this threatens the long-term financial sustainability of the trust.”

The trust plans £14m saving for 2012–13, but this will be “challenging” given that last year it saved £9.8m less than it had planned, Monitor said.

According to the regulator, Sherwood Forest has breached Condition 2 (the general duty to exercise its functions effectively, efficiently and economically) and Condition 5 (the governance duty) of its authorisation terms.

Monitor’s Board has not yet decided what action to take.

Portsmouth Hospitals Trust has taken steps to reduce its bed capacity, including the cancellation of its normal ‘winter’ increase, to improve its finances.

The foundation trust has seen its budget deficit increase due to “higher than expected” demand on beds driving increased use of temporary staff.

According to board papers for August, the trust has achieved its service delivery and quality targets only at the cost of financial failures.

All six of the trust’s financial indicators received a ‘red rating’, and the overall deficit (£5.9m) was £2.2m worse than had been planned.

The trust reported that “over-plan pay costs” due to “over-plan activity levels” were “only partially offset” by the increased income from that activity, with increased spend on temporary staff being the main problem factor.

It stated that the overall workforce “remains at levels that are not sustainable moving forward”.

The trust plans to reduce its temporary and permanent staffing costs through “actions to reduce bed capacity”, including “closing down ‘winter’ capacity”.

While the Portsmouth hospitals have achieved “improved or stable performance” against their service delivery and quality priorities, the board concluded that meeting clinical need was not viable.

Northern Lincolnshire and Goole Hospitals NHS Foundation Trust has some of the highest mortality rates in the country, a new report has found.

Research showed the trust to be in the top ten for deaths in England and pointed towards a host of issues including poor hygiene, low staff levels and a lack of collective responsibility.

Dr Liz Scott, Medical Director at the Trust, said the issue was for the “whole health community” to consider across the region and that “all possible factors” are being addressed to tackle the problem.

The report, which was commissioned by NHS North and North East Lincolnshire CCG, found the foundation trust has a higher than average mortality ratio.

It found that northern Lincolnshire has a complex healthcare system which has resulted in a host of trusts but not one which is in overall charge.

Concerns were also raised in the report around access to specialist services out of hours, Macmillan nurses, hospice facilities and end of life care.

A 40 point action plan has now been devised to address and tackle the issues in an effective and timely manner. But the report advises that more information is needed to understand the clinical factors behind the high mortality rates and why levels of care for deteriorating patients are below other trusts in the country.

“The trust has set up a mortality task group, which is investigating every area where there is a possibility of a higher mortality ratio and is also reviewing every death that occurs to see if anything could have been done differently,” said Dr Scott.

“Their purpose is for us to monitor progress over time to make sure that we do all we can to provide the highest quality of care.”

The CCG commissioned the report after the DH introduced new procedures to improve mortality rates throughout trusts last October.

Professor Sube Banerjee, who led the development of the National Dementia Strategy, is to join Sussex Partnership NHS Foundation Trust in a strategic role.

From November, he will be Professor in Dementia and Associate Dean for Strategy at Sussex Partnership NHS Foundation Trust and Brighton and Sussex Medical School.

Formerly NHS London’s Clinical Director for Dementia and Professor of Mental Health and Ageing at the Institute of Psychiatry, Professor Banerjee is expected to play a key role in improving dementia care services across Sussex.

Lisa Rodrigues, Chief Executive of Sussex Partnership, said: “In Sube Banerjee we have a world-class leader in dementia. His arrival is both a recognition of the importance of dementia in Sussex and an acknowledgement of our achievements so far.”

“There are fantastic things that are being done across Sussex and the south to improve care for people with dementia but there is also much more that needs to be done,” commented Professor Banerjee. “I have found opportunities and possibilities here that I have not seen elsewhere.”