How do organisations enter special measures for quality?
NF: Based on a Care Quality Commission inspection, a trust will be placed in special measures for quality if the leadership of that trust is rated ‘inadequate’ and if it’s rated ‘inadequate’ in one or more of the other key domains (safe, effective, caring and responsive).
Being in special measures for quality is in the public domain. It will be reported in the local (and sometimes national) press. All the staff will know, and many in the local population will also be aware. That can have a big impact on the public and patients.
Why does your research on it matter?
NF: There's very limited knowledge and evidence about interventions to improve low-performing health care organisations. We know little about the unintended consequences of those interventions and their costs. The special measures for quality regime has been a national improvement initiative to improve low-performing health care organisations, and it's important to find out the impact of that programme.
What did your work involve?
NF: We carried out a rapid systematic literature review to develop a theoretical understanding of organisational failure and turnaround – this included literature in the health care sector but also in education and local authorities. We then quantitatively looked at performance trajectories of 62 NHS trusts over a period of six years, to evaluate the impact of improvement interventions for trusts under special measures for quality. We conducted interviews at national level to understand the programme, and conducted eight case studies of trusts either in special measures or the challenged providers regime to understand how they responded.
What are the interventions offered to trusts in special measures?
NF: NHS Improvement have provided three main interventions. One is an improvement director to work in and alongside the organisation. The second is the opportunity to buddy with another organisation. And the third is the opportunity to bid for central funding for quality improvement. These interventions were delivered within the context of significant leadership changes, including at board level.
What was the impact of the interventions?
NF: In terms of the improvement director, when they used a more coaching style and offered tactical advice, that was viewed as helpful. There was also some debate about the length of time that improvement directors should be in organisations – some CEOs wanted them for longer.
In terms of buddying, there was a mixed picture about how often it actually happened and it seemed to work better when the buddy was in a similar context. On the additional funds, we conducted an analysis of what they spent those on. These were mainly used to cover additional posts and external consultants and experts, which brought a risk of spending their way out of special measures.
More broadly, changes to the senior leadership were seen to be a key driver for change. In all the examples we looked at, the board was completely changed and the chief executive either resigned or was forced out. Bringing new ideas and approaches was seen as very helpful, especially if they had previous experience of special measures of quality.
But stability of leadership remained a big issue. New leaders are not given enough time to embed changes. If improvements aren't being made after nine to 12 months, they're often moved out and a new team brought in, which isn't always helpful. That can happen several times over in a trust that's really struggling.
What else did you find?
NF: Most previous research hasn’t looked at the role that the wider local health system plays. For some organisations, system partners pulled away from them because they didn't want to be associated with an organisation in special measures. For others, system partners were helpful in supporting them to move out of special measures.
CSJ: While trusts were in special measures we found some improvement in mortality rates, and also some improvements in meeting the four-hour A&E target, but not in measures such as cancer waits. That might be because it needs more than just the hospital doing things – it requires engagement across the system.
What was the impact on staff working for an organisation in special measures?
NF: It was reported to us that it became harder to recruit staff once you're labelled as being in “special measures for quality”, especially if you're in an area where there's a choice of organisation to work for.
For the staff already at the trust, it was a mixed picture. Many were initially devastated, angry or ashamed. But some others did also feel relief, and felt it would force changes. And then with the benefit of hindsight having been through it, they would say it was necessary and a catalyst for change, albeit that wasn’t universal.
CSJ: We did notice some evidence in improved sickness absence once trusts had left special measures. The staff survey results showed some improvement as well. The samples are quite small, but there was some indication of improvement there.
What lessons are there for trusts in special measures in how they engage with staff?
NF: Improving relies on better staff morale and culture, and requires positive engagement and investment in staff. That means developing strategies for better communication, listening to the concerns that staff have, tackling bullying or insular cultures, regular staff appraisals, celebrating staff success, and investing in education training.
Better engagement with staff could well be connected with what we found on improved sickness absence once a trust had left the measures.
Were there any lessons for trusts that particularly stood out?
NF: The lessons for trusts rely on lessons being taken on by regulators. What stood out for me for trusts was the importance of engaging staff and creating an organisational culture that supports learning, as well as looking beyond standard metrics to measure other things that you think are important.
But unless the regulators change, it’s hard for trusts to change. There's a tendency to look in silos at improvement, rather than looking across the whole organisation, as well as the system, to develop a strategy and the capability for how you do that. An organisation needs headroom to improve, and the regulators need to give it.
Is that happening?
NF: NHSE/I have just announced proposals to replace the current special measures regime for providers and commissioners with the “Recovery Support Programme”, which will have more emphasis on system working, so that hopefully will be a positive move.
One of our main lessons for regulators from our work is that organisations need to be given time and headspace. If things haven’t going well after about nine or 12 months, there's a tendency to chuck everyone out and start again. But you need some stability of leadership to embed the necessary changes, and let them come to fruition. That’s stable leadership over a minimum of three years.
What are the other main lessons for regulators?
NF: To understand the emotional cost of a trust going into special measures for quality. We’ve discussed that with regulators at various different levels, and they do seem to accept it. Helping people in organisations to improve means you must not name and shame them. The importance of the role of the system is also being taken on board.
There’s also a large amount of avoidable duplication where organisations report the same information to different bodies, which is time consuming and overwhelming. As a trust, if you are too busy ‘feeding the beast’, you haven't got time to get your head up and think about improving in the longer term.
CSJ: They also need to develop more skills for working with data and statistics. The standard metrics used may also not be sensitive enough to pick out certain issues of concern within a specific organisation, which can lead to a false sense of security that a trust might be doing well or ok, but actually they should be looking elsewhere. The strategy to support improvement needs to be more trust specific.
If you can look at those things continuously over a longer period of time and with more effective methodologies, you can much better work out whether something's going in the right direction or not.
How do the finance and quality regulators complement each other for a troubled trust?
CSJ: It's much more common for a trust to go from special measures for quality into special measures for finance than to go the other way (from financial problems into special measures of quality).
NF: We looked at the journeys of trusts in special measures for quality, and some then went into special measures for finance. So there is a concern that trusts in special measures for quality spend their way out of it and end up in financial trouble.
Could patients could see a difference from all this?
NF: Yes, there were some improvements in indicators that directly impact on patients, such as improvements in meeting the four-hour A&E target. The reduction in staff sickness could also benefit patients in terms of continuity of care and fewer bank and agency staff.
People want their local hospital to be performing well, and to be a hospital that cares about patient experience and which engages with patients and the public. Trusts not in special measures are more likely to be doing that.
What surprised you most in your own findings?
CSJ: Improvements in quality are quite variable from trust to trust, and the way that trusts respond has been very different too. Some go forward with robust quality improvement methodologies and practices, which seem to stand them in good stead further on, yet others don't seem to do that. There were a few, not many, who once they came out of special measures actually went back into special measures afterwards, which means they're not doing everything correctly.
*To read the full report, Rapid Evaluation of the Special Measures for Quality and Challenged Provider Regimes: A mixed-methods study, please click here. You can also find this executive summary of the report, as well as this slide set with the main findings.
Fulop N & Sherlaw-Johnson C (2021) “Special measures for quality: a Q&A on the impact of improvement interventions in NHS trusts”, Nuffield Trust Q&A.