By David Williams
2 February 2010
Problems at Mid Staffordshire and Basildon foundation trusts caused an awkward year for outgoing Monitor chair Bill Moyes. But standards are rising, he tells David Williams
Bill Moyes’ final year as executive chair of the foundation trust watchdog Monitor proved to be a little more eventful than he might have wished for.
In a one-to-one interview with Public Finance, he recalls the sequence of events during the final weeks of 2009 that thrust this usually low-profile regulator into a glaring public spotlight.
In November, data published from analysts Dr Foster Health listed 27 hospital trusts with the highest death rates in England. The top four were all foundation trusts – the governance of which is overseen by Monitor – and the worst was Basildon & Thurrock University Hospitals.
Days earlier that trust had been the subject of a report from the Care Quality Commission outlining severe shortcomings around hygiene and patient safety. Monitor sent in a taskforce to oversee an improvement programme bringing care quality up to acceptable standards. On the same day, Moyes removed the chair of Colchester Hospital University trust, after finding problems with governance and care.
Many observers were reminded of yet another patient safety scandal, which blew up in early-2009 around Mid Staffordshire NHS Foundation Trust.
To some it has come as a disappointment that in 2009 foundation trusts appeared to be no less vulnerable to lapses in care standards than others – for all their independence from the health secretary and their proven track record of good financial management.
But Moyes remains committed to the idea, and even argues that the negative publicity of the past year will ‘strengthen the [foundation trust] brand’ in the public imagination by showing that regulators are willing and able to act decisively.
He says that overall care standards are improving, and claims that the real lesson from November’s Dr Foster report was that it showed a 7% reduction in the overall rate of unexplained unnecessary deaths.
Moyes describes a ‘step-change in [NHS] performance’, which he attributes in large part to the advent of foundation trusts – with their boards of governors representing patients and clinical staff, who can scrutinise care standards ward by ward.
So what went wrong in Mid Staffordshire? Monitor had made the hospital a foundation trust in 2008, despite data suggesting that at least 400 more people had died there over the previous three years than would normally be expected.
Moyes admits that ‘we probably came down on the wrong side of the line’, but insists that simple death rate data is not a reliable barometer of care quality. Crucially, he adds that Monitor would not have approved the application had it known that the Healthcare Commission was conducting an inquiry into clinical standards at the time.
He stresses that those lessons were learned and put into practice in the case of Basildon. Then, far from being a chaotic situation with two regulators intervening in the same trust at the same time, Moyes says the action was co-ordinated and the two parties were in constant dialogue.
‘I don’t think the regulatory system is anything like as complicated or as ill-structured as people would suggest,’ he tells PF. Having Monitor oversee finance and governance in foundation trusts while the CQC scrutinises patient care is a strength, not a hindrance.
‘If there’s a trade-off in your judgement as a regulator between how tough you are on money and how tough you are on quality, there’s a tendency in the end to say “sort your finances out”,’ he says. ‘There’s a real advantage to having the CQC, that’s able to reassure the public that [Monitor] is not forcing the trust to do things that damage patient care.’
But Mike Jackson, senior national officer for health at Unison, argues that is exactly what happened at Mid Staffordshire. ‘They were desperate to drive down costs and reduce their deficit to get foundation trust status,’ he says. The greater the pressure to create more foundation trusts, ‘the greater the need for vigilance to ensure people are not taking short cuts’.
Gail Cartmail, Unite’s assistant general secretary for the public sector, adds: ‘The recent spectacular failings of a significant number of foundation trusts cannot be glossed over. Public trust will have been dealt a severe blow where promises of even better services have failed to materialise and instead incidents of high mortality rates are revealed.’
Moyes maintains that, with more collaboration between quality and governance regulators, systemic failure can be detected before becoming catastrophic.And he is still loyal to the goal for all hospital trusts to attain foundation status, appearing aggrieved that to date only 125 have made the grade.
‘What you’re saying, if you say it’s not possible, is that you are prepared to have some trusts or hospitals which are not financially viable and are not well run. I can’t believe the public will accept that, and I don’t believe politicians should.’
It adds up to a fairly staunch defence of the policy status quo. But, in the guarded language of senior public servants, Moyes suggests that parts of the NHS structure are not working quite as well as they should.
Strategic health authorities, whose role is to manage non-foundation trusts on behalf of the Department of Health, are not driving improvements in governance effectively, consistently or transparently enough.
‘We need to see some real energy put into that,’ he says. ‘So long as we have SHAs, they have the task of preparing hospitals to be foundation trusts. Therefore we should see SHAs giving that real priority, but the position is patchy across the country.’
There are doubts over whether the CQC, with its sprawling remit covering health and social care, will ever be able to fulfil its duties effectively.
‘I’m in favour of quangos [like Monitor] that are defined for specific purposes, with a clear focus, not necessarily very big,’ says Moyes. ‘I’d rather have more of those than a very small number of very large organisations with very wide remits.’
And there is also coded criticism of the DoH, for its repeated interference in the regulatory framework.
‘The focus of quality regulation has changed three times in the past ten years. We’ve had the Commission for Healthcare Audit and Inspection, then the HC, and now the CQC. In each case, the reorganisation has probably meant that there has been a pause in developing our system of quality regulation.
‘There’s been a lot of change and some stability would be good.’
Stability, though, is a luxury the NHS is unlikely to be granted in the years to come. Moyes calls on primary care trusts to take the lead in reconfiguring local services so they can improve efficiency and provide truly world-class clinical standards. But he warns that this must involve breaking up the established model based on traditional district general hospitals.
‘Health services have to change, all the time – they cannot remain static,’ he says. This is something that Moyes, having led Monitor through its first six years, would know better than most.
2 February 2010
Problems at Mid Staffordshire and Basildon foundation trusts caused an awkward year for outgoing Monitor chair Bill Moyes. But standards are rising, he tells David Williams
Bill Moyes’ final year as executive chair of the foundation trust watchdog Monitor proved to be a little more eventful than he might have wished for.
In a one-to-one interview with Public Finance, he recalls the sequence of events during the final weeks of 2009 that thrust this usually low-profile regulator into a glaring public spotlight.
In November, data published from analysts Dr Foster Health listed 27 hospital trusts with the highest death rates in England. The top four were all foundation trusts – the governance of which is overseen by Monitor – and the worst was Basildon & Thurrock University Hospitals.
Days earlier that trust had been the subject of a report from the Care Quality Commission outlining severe shortcomings around hygiene and patient safety. Monitor sent in a taskforce to oversee an improvement programme bringing care quality up to acceptable standards. On the same day, Moyes removed the chair of Colchester Hospital University trust, after finding problems with governance and care.
Many observers were reminded of yet another patient safety scandal, which blew up in early-2009 around Mid Staffordshire NHS Foundation Trust.
To some it has come as a disappointment that in 2009 foundation trusts appeared to be no less vulnerable to lapses in care standards than others – for all their independence from the health secretary and their proven track record of good financial management.
But Moyes remains committed to the idea, and even argues that the negative publicity of the past year will ‘strengthen the [foundation trust] brand’ in the public imagination by showing that regulators are willing and able to act decisively.
He says that overall care standards are improving, and claims that the real lesson from November’s Dr Foster report was that it showed a 7% reduction in the overall rate of unexplained unnecessary deaths.
Moyes describes a ‘step-change in [NHS] performance’, which he attributes in large part to the advent of foundation trusts – with their boards of governors representing patients and clinical staff, who can scrutinise care standards ward by ward.
So what went wrong in Mid Staffordshire? Monitor had made the hospital a foundation trust in 2008, despite data suggesting that at least 400 more people had died there over the previous three years than would normally be expected.
Moyes admits that ‘we probably came down on the wrong side of the line’, but insists that simple death rate data is not a reliable barometer of care quality. Crucially, he adds that Monitor would not have approved the application had it known that the Healthcare Commission was conducting an inquiry into clinical standards at the time.
He stresses that those lessons were learned and put into practice in the case of Basildon. Then, far from being a chaotic situation with two regulators intervening in the same trust at the same time, Moyes says the action was co-ordinated and the two parties were in constant dialogue.
‘I don’t think the regulatory system is anything like as complicated or as ill-structured as people would suggest,’ he tells PF. Having Monitor oversee finance and governance in foundation trusts while the CQC scrutinises patient care is a strength, not a hindrance.
‘If there’s a trade-off in your judgement as a regulator between how tough you are on money and how tough you are on quality, there’s a tendency in the end to say “sort your finances out”,’ he says. ‘There’s a real advantage to having the CQC, that’s able to reassure the public that [Monitor] is not forcing the trust to do things that damage patient care.’
But Mike Jackson, senior national officer for health at Unison, argues that is exactly what happened at Mid Staffordshire. ‘They were desperate to drive down costs and reduce their deficit to get foundation trust status,’ he says. The greater the pressure to create more foundation trusts, ‘the greater the need for vigilance to ensure people are not taking short cuts’.
Gail Cartmail, Unite’s assistant general secretary for the public sector, adds: ‘The recent spectacular failings of a significant number of foundation trusts cannot be glossed over. Public trust will have been dealt a severe blow where promises of even better services have failed to materialise and instead incidents of high mortality rates are revealed.’
Moyes maintains that, with more collaboration between quality and governance regulators, systemic failure can be detected before becoming catastrophic.And he is still loyal to the goal for all hospital trusts to attain foundation status, appearing aggrieved that to date only 125 have made the grade.
‘What you’re saying, if you say it’s not possible, is that you are prepared to have some trusts or hospitals which are not financially viable and are not well run. I can’t believe the public will accept that, and I don’t believe politicians should.’
It adds up to a fairly staunch defence of the policy status quo. But, in the guarded language of senior public servants, Moyes suggests that parts of the NHS structure are not working quite as well as they should.
Strategic health authorities, whose role is to manage non-foundation trusts on behalf of the Department of Health, are not driving improvements in governance effectively, consistently or transparently enough.
‘We need to see some real energy put into that,’ he says. ‘So long as we have SHAs, they have the task of preparing hospitals to be foundation trusts. Therefore we should see SHAs giving that real priority, but the position is patchy across the country.’
There are doubts over whether the CQC, with its sprawling remit covering health and social care, will ever be able to fulfil its duties effectively.
‘I’m in favour of quangos [like Monitor] that are defined for specific purposes, with a clear focus, not necessarily very big,’ says Moyes. ‘I’d rather have more of those than a very small number of very large organisations with very wide remits.’
And there is also coded criticism of the DoH, for its repeated interference in the regulatory framework.
‘The focus of quality regulation has changed three times in the past ten years. We’ve had the Commission for Healthcare Audit and Inspection, then the HC, and now the CQC. In each case, the reorganisation has probably meant that there has been a pause in developing our system of quality regulation.
‘There’s been a lot of change and some stability would be good.’
Stability, though, is a luxury the NHS is unlikely to be granted in the years to come. Moyes calls on primary care trusts to take the lead in reconfiguring local services so they can improve efficiency and provide truly world-class clinical standards. But he warns that this must involve breaking up the established model based on traditional district general hospitals.
‘Health services have to change, all the time – they cannot remain static,’ he says. This is something that Moyes, having led Monitor through its first six years, would know better than most.
