In March, the then Cabinet Secretary for Health and Wellbeing, Alex Neil, was made aware of concerns about quality of care and patient safety by a number of senior consultants at Aberdeen royal infirmary. The Scottish Government acted swiftly in response to that contact and within a week Healthcare Improvement Scotland had arranged to begin the first stage of the work that has culminated in the reports that were published on the HIS website yesterday morning: “Aberdeen Royal Infirmary: Short-Life Review of Quality and Safety” and the report on care for older people at Aberdeen royal infirmary and Woodend hospital.
A third report on NHS Grampian has also been produced by the Royal College of Surgeons of England. The board has published on its website the terms of reference and the recommendations arising from that review, but it has not yet published the full report because of legal action that has been initiated by individuals named in it. However, Healthcare Improvement Scotland has seen the report and has made its own recommendations to address many of the issues that the college raised.
The reports highlight significant failings in the management of NHS Grampian that, as the leader of the HIS review team has said, make sobering reading and which we take very seriously indeed. They also highlight the important role of the inspection regime that this Government has put in place to scrutinise safety and quality in the national health service in Scotland. This statement sets out the Scottish Government’s response to the findings of those reports and the action that we expect NHS Grampian to take both immediately and in the longer term.
It is important to make clear up front that HIS’s work did not identify consistent or widespread concerns about patient safety. Without minimising the importance of some of the concerns raised by the HIS reports, I note that the review highlighted that Aberdeen royal infirmary is not significantly different from the Scottish average for a range of indicators of quality and safety of patient care, including the hospital standardised mortality rate and infection rates. During the inspection of care for older people, patients and carers also provided very positive feedback on their experiences, with 89 per cent stating that the care that they had received was good and staff being described as “compassionate and considerate”.
However, the report highlights a number of issues relating to leadership, management and staffing that, if not addressed immediately and decisively, pose a clear risk to the quality of patient care. That they have not yet impacted adversely on the care of patients is, as the report makes quite clear, due to the hard work of dedicated and highly committed front-line staff who have gone above and beyond to compensate for weaknesses in NHS Grampian’s structures and processes. I put on record my sincere thanks to every member of staff in Grampian for their work in ensuring that their patients continue to get the best possible care, and I assure them that we will do everything possible to support them in making things better.
The review was a complex and thorough piece of work. Headed up by Angus Cameron, who is currently medical director at NHS Dumfries and Galloway, the HIS review team agreed with NHS Grampian that it would examine two main areas, the first of which was the culture, leadership, values and behaviours in operation in the board. Although such things can be difficult to pin down, they shape the day-to-day interactions in any organisation and are essential in supporting the on-going delivery of a safe and high-quality healthcare system. Secondly, the review team looked in detail at the actual quality and safety of care in a focused number of specialties and services, including the emergency department, general surgery and care of the elderly, with a clear focus on outcomes and the experiences of patients using those services.
The review team worked with NHS Grampian for more than five months and gathered information from a wide range of sources. In addition to analysing nationally available data, the team spoke to around 530 members of staff; received feedback from 362 patients and carers; reviewed 49 case files; looked at 32 complaints; and analysed 13 adverse events. Its work has created a rich picture of healthcare provision in Grampian.
The picture that Dr Cameron’s team has painted is a worrying one. The review describes a climate of mistrust between clinicians and senior managers in several specialties; unprofessional behaviour by a number of consultants that impacted on morale and the effectiveness of the service and which went largely unchallenged; and a failure to respond effectively to concerns about staffing pressures and vacancies. There is also evidence that managers were distant, trainees were inadequately supported, complaints were poorly handled and systems of governance and performance management were weak, muddled or, indeed, absent.
Make no mistake: those things are unacceptable in the NHS in Scotland, and they will be resolved. Let me send the clear message that, no matter who a person is or at what level they work in the NHS, the behaviours that are highlighted in the HIS review will not be tolerated in our national health service.
The key issue now must be how those findings are responded to. The report on quality and safety contains 13 recommendations, which are grouped under the headings of “Patient outcome”; “Leadership and culture”; “Governance and accountability”; “Staff governance”; and “Complaints management”. They are accompanied by 22 more detailed areas for improvement in the report on care for older people.
I visited Aberdeen royal infirmary yesterday and spoke to staff and the board to emphasise how much importance we attach to seeing real improvements being made. I was given assurances that NHS Grampian accepts every single one of the recommendations and that, under the leadership of its new interim chief executive, Malcolm Wright, it has already begun work to address many of those areas. The board has apologised for those instances in which its patient care did not meet the required standard and has committed to improving leadership, management and engagement at the ARI and across NHS Grampian.
The report highlights some particular concerns around nursing staffing levels and vacancy rates. The board is continuing to experience challenges around recruitment, with factors such as the high cost of living and the competitive job market contributing to the challenge. However, the board invested in the creation of 100 additional nursing posts in the year to March 2014 in priority areas such as theatre, the emergency care centre and mental health services. A further almost 100 posts have been added to the nursing establishment since March, and funding has been allocated for up to 40 posts in 2015-16.
NHS Grampian is also actively recruiting to vacant medical and nursing posts using every means at its disposal, including social media and executive search as well as more traditional means, such as medical careers events and graduate nurse recruitment, which resulted in 88 graduate nurses from Robert Gordon University being placed in 2014.
The HIS reports on NHS Grampian are challenging to read, but they must be seen as a vindication of our unflinching resolve to shine a light on poor practice through the systematic use of independent inspection processes, and to hold to account healthcare providers that fail to provide the quality of care that the people of Scotland deserve and the support that those who work in the NHS in Scotland have the right to expect.
We recognise that we have a role to play in supporting the board to improve, and that improvement will not happen overnight. The Scottish Government is providing record levels of funding to NHS Grampian to support its recruitment efforts. In 2015-16, NHS Grampian’s resource budget is planned to increase by 4.4 per cent, to £812.6 million—the increase is above inflation and is the largest increase of any board—and it previously increased by 4.6 per cent in 2014-15. Those increases include sums of £15.5 million this year and £17.5 million next year to move the board closer to its target share under the NHS Scotland resource allocation committee funding formula. The intention is that, by 2016-17, NHS Grampian, along with all the other territorial boards, will be no more than 1 per cent away from NRAC parity.
In addition to the financial support that we are continuing to provide, we have put in place a comprehensive support team to advise and work alongside the new interim chief executive and his executive team in implementing the improvements that are needed to strengthen key systems, structures and processes. That vital organisational development will be supported by an additional allocation of £100,000 to help to develop and strengthen leadership at all levels within NHS Grampian.
We are also fast-tracking the identification of a new chair for the board. Interviews are taking place today, and there is an expectation that the new chair will take up post very early in the new year.
The report of the quality and safety review makes it clear that the board is expected to develop a detailed and considered improvement plan that sets out exactly how it intends to implement the report’s recommendations, along with timescales for action and clear accountability. The plan will also be expected to set out clearly what success will look like. However, these are serious issues and although we expect immediate action to be taken in relation to several of the key findings, we cannot expect changes to culture and leadership to happen overnight.
The changes must be taken forward in partnership with clinical and staff-side representatives from the very beginning if they are to be woven through the fabric of the organisation—as we expect them to be—and we must accept that that will take some time. The Scottish Government will monitor the implementation of the plan very closely in the coming months, and I will receive regular updates on progress as work goes forward.
This has been, and will continue to be, a difficult and challenging time for NHS Grampian. However, by putting patient outcomes and patient experiences at the heart of its services—and with the involvement of the committed and dedicated staff who we know work in NHS Grampian—I am confident that NHS Grampian can turn the situation round and begin to live up to its ambition of providing top-class healthcare services for all the people of north-east Scotland.