While leaders squabble, patients suffer – special report on health care in Stockport
Share Comments By Jennifer Williams 18:06, 14 APR 2019 Updated 18:24, 14 APR 2019 News (Image: Manchester Evening News) Get the biggest daily stories by email Subscribe See our privacy notice More newsletters Thank you for subscribing We have more newsletters Show me See our privacy notice Could not subscribe, try again later Invalid Email Stockport has had issues with its health services for years, if not decades.
Until very recently, Stepping Hill hospital had seemed permanently on the brink of special measures. A series of dire inspection reports had raised concerns over patient safety, nursing numbers and the training of junior doctors, while A&E waiting time figures bumped along – year after year – among the worst in the country, despite the hard work of committed staff.
Its buildings were outdated, its emergency department too small. The trust has been running a vast deficit, too, a black hole of tens of millions that appeared all but impossible to wipe out, a situation not unconnected with a heavy reliance on bank and agency staff, thanks to a difficulty recruiting. A vicious spiral that will be familiar to other NHS trusts where things have gone wrong.
From last summer until this week, the hospital had also been overseen by an ‘improvement’ board of senior health officials from Greater Manchester and the Department of Health, tasked with turning it around.
Beneath the surface, however, tensions between the three key players in the equation – the commissioners, the council and the hospital – have also long simmered, never really going away.
As in other areas, each has had, traditionally, its own separate role and separate budgets. The borough's clinical commissioners had chosen what health services to buy on behalf of the government. The council had, by and large, then provided the social care part of that: the support for the elderly, disabled and those recovering from illness, outside of hospital.
Ann Coffey (Image: Getty Image) And the acute NHS trust that runs Stepping Hill itself had, largely, provided the hospital care.
But it had never really worked, says Stockport MP Ann Coffey. The area’s system as a whole has long relied too heavily on the hospital, with too little care available in the community. As a result, people had been stranded in hospital when they didn't need to be, A&E waits spiralled, while care has been unnecessarily expensive.
“This has been going on forever,” she says.
“We have had too many hospital beds, a particularly ageing population, a dependency on the hospital and not enough community infrastructure.
“If you’re going to fix that, you have to get the money out of the hospital itself and back into the community, because otherwise, you can’t change that circle – or stop it missing its A&E targets.”
Over the years, she adds, friction between those at the top of the three bodies in charge has compounded the situation.
“There are three organisations that fight like cat and dog: one is the council, one is the hospital and the other is the commissioner,” she says.
“They’ve got three chief executives with different accountabilities and budgets. So the hospital has been a merry-go-round of everybody blaming each other.”
In an attempt to address all those root causes, local health and social care chiefs launched Stockport Together.
Stepping Hill Hospital (Image: MEN) The idea – more or less the same as in other Greater Manchester boroughs, such as Tameside and Oldham – was to have a single, pooled financial budget, the three bodies eventually working as a single unit under one legally responsible officer, sharing risk, easing the pressure on the hospital, improving care and saving money.
Despite some evidence, even then, of fundamental tensions at a senior level, this time last year each one of the organisations put a little over £2m or so into a shared pot, to get things going.
Greater Manchester’s devolved healthcare board also supplied around £20m in one-off funding to try out different programmes, including a walk-in centre at the hospital, more care via GPs – instead of the hospital – for long-term conditions, and extra cash for support like physio.
Since then, things at Stepping Hill have been very slowly getting better, albeit far from where they need to be. Pressure ulcers have reduced, serious incidents came down, and while the latest inspection report, published in December, still highlighted patient safety issues, it also showed a number of other improvements. Finances are still bad, but not as bad as they were.
In the council's view, however, things simply hadn't improved enough.
In a letter to the rest of the partnership at the start of February, the town hall suddenly said it had changed its mind about sharing money and risk.
The first year of pooled financial arrangements had not produced the cash savings they had expected, said the letter, ‘while the performance issues which have been of significant concern are now untenable’.
William Wragg (Image: UGC) Hinting at those continued underlying tensions, it also noted ‘the deterioration in the partnership’.
The borough’s three MPs, Ann Coffey, Hazel Grove’s William Wragg and Cheadle’s Mary Robinson, were taken aback.
They believed the new plan could never be expected to turn things around overnight, after years of acute problems.
Rather, they blamed relationship breakdown at the most senior level for the plan grinding to a halt.
“Over the years there has been continual friction between the CCG, the foundation trust and the council with various CEOs blaming each other for their difficulties in delivering health and social care and for their respective budget pressures,” they wrote in a furious letter to each of the partners.
“CEOs have come and gone, but the friction continues.”
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One MP in another part of Greater Manchester says senior officials from Greater Manchester’s devolved health partnership have been trying to mediate between the three organisations for months, but to no avail, adding: “Stockport’s a basketcase. It beggars belief, really.”
An exasperated senior health official agrees that while other boroughs have also struggled to merge their social care and NHS services, Stockport has an extra problem.
Stockport town hall (Image: MEN) “The bottom line is that it’s hard to quickly deliver the savings the council is seeking,” they say.
“Other areas have found it difficult too, but there hasn’t been the same issue in terms of relationships.”
Shortly after the council withdrew from the pooled funding arrangements, so too did the hospital. Within the mix also appears to be an ongoing disagreement about who would be the 'accountable officer' in charge of the new set-up – the council's chief executive, or the CCGs.
Stockport council is now going to expand and invest in its own social care plans in the community, although all three organisations say they are committed to still working together and have put some one-off money into the pot for this coming year.
In a joint statement, they said of the original arrangement: “Unfortunately, not everything has gone as expected, but at a time of increased demand and reduced resources, we have to ensure we’re improving health and social care for all.
“That’s why Stockport Together is committed to developing neighbourhood care further to help our residents to remain healthy and independent.”
Nevertheless the underlying stalemate also raises questions for Greater Manchester’s own health devolution vision, which has been designed to create a collaborative approach to healthcare locally.
In the meantime Ann Coffey believes that until Stockport’s three main health organisations find a way to agree, the ‘merry-go-round’ of arguments will continue – and for patients, care will not get significantly better.
Jon Rouse, chief officer for Greater Manchester Health and Social Care Partnership, whose team has been involved in trying to turn the situation around “You have to stop the situation where they are trying to protect their own budgets,” she sighs, “battling and blaming each other.”
What the hospital trust says Louise Robson, Chief Executive of Stockport NHS Foundation Trust pointed to a range of improvements introduced at the hospital, including routine out-of-hours GP appointments, a community falls service and GP home visiting service.
Improvements at the trust have helped it recruit, she said, meaning it has been able to offer jobs to 80 new nurses since January.
“Like many trusts across the country Stockport NHS Foundation Trust has had some significant challenges in recent years, which in 2016 led to the “requires improvement” rating from the CQC,” she said.
We have a growing elderly population, many with complex needs, who often stay in hospital for long periods of time while health and care services are organised to support them in going home. Unlike other parts of the country we have relatively few alternatives to A&E when people believe they need urgent care.
“Financial resources are tight, and we have previously struggled to recruit to key clinical and nursing posts.
Louise Robson “We now have a clear view of what we need to do to tackle the issues facing the local health and care system, and thanks to the commitment, skills and enthusiasm of our staff we have seen some real improvements in both the hospital and community services we provide.
“This was recognised last year by the CQC who said we had made significant improvements for our patients, and just last week our regulators acknowledged all the positive changes we have made.
“During 2018-19 we worked hard to achieve our financial plans for the year, which we delivered without compromising the quality of our services.
“We have invested in new equipment for the benefit of our patients and staff, and have robust plans in place to achieve a much reduced deficit of £3.6m in 2019-20. This is a significant improvement on where we have been in recent years.
“The work we have done in partnership with other organisation has paid dividends over the last year, and has helped to address a number of the challenges of caring for elderly people, and maintaining a good flow of people through our hospitals to reduce the pressure on A&E services.”
She added: “We are not complacent about the improvements we have made. We know we still have more to do, but we remain committed to working with our partners to make a positive difference to the lives of local people, and we are continuing to make progress on transforming health care via the Stockport Health Partnership Board.”
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