NEWS FOCUS: The Modernisation Agency team has arrived at your trust.But what will it actually do? Alison Moore tracks the progress of a visit at a no-star trust. What do both 'sides'stand to gain?

You might think that being part of the Modernisation Agency's visits team - informally known as the 'Trusts In Trouble' team - is a tough job.

Not only do you have to live with an unfortunate acronym, you have to tell trusts where they are not up to scratch and how they can improve. But the agency's deputy director of service development, Deborah Jones, and her team of hand-picked secondees, seem to relish their task. 'There are huge expectations of us, but we are not a panacea, ' she says.

Thirteen members of the team have just finished a two-week visit to the 'no-star' Oxford Radcliffe Hospitals trust - one of the largest and most complex they have ever tackled and, insists Ms Jones, as much of an opportunity for them to benefit as it is for the trust.

'Oxford Radcliffe is enabling us to learn to provide our services in a much more cohesive, collegiate way - they are doing us a favour, ' she says. Chief executive David Highton invited the team in. 'He is a seriously well-respected individual - he obviously recognises there are difficulties within the organisation, ' she says.

The visit marks an evolution from the team's earlier style, which concentrated on a lot of one-day visits. 'It was very superficial - it was much more about marketing the need to think about waiting times, ' says Ms Jones, who began working for the National Patients Access Team 18 months ago from Somerset health authority.

Visits today are far more indepth and are beginning to look at the whole health economy, not just the trust. Waiting lists and trolley waits may be the visible manifestations of deeper problems, which encompass primary care and its interaction with the secondary sector as well as acute trusts.

That is almost certainly the case in Oxford, where there is widespread recognition that the problems which led to the Radcliffe getting zero stars in the recent performance tables are health economy-wide.

'It is a county-wide acute trust.

We have been spending much more time with primary care colleagues and colleagues in community hospitals, ' says John Turner, an associate director of senior development, who is on secondment from James Paget Healthcare trust in Ipswich.

'We are looking at slices within the organisation rather than looking down functional silos. It is a complex assignment - we are looking at four main acute sites , and we are also making links with the Nuffield Orthopaedic Centre.'

The scope of the team's visit is sorted out beforehand, when there is a preliminary trip to gather data and decide what is to be looked at.

It will be followed by a feedback session to managers within three to four weeks, which will include recommendations for change.

Much of the team's time is spent talking and listening - often to people at the grassroots, such as medical secretaries and records clerks. The reaction from staff can be mixed. 'Often we are required to go into trusts at short notice.

We put in a lot of preparation, but there are still individuals who are a little surprised or confused and do not know what we are about, ' says Ms Jones. 'Often we are thought of as the waiting-list hit squad, and That is quite unhelpful.

'I know that I can be challenging - and so can the rest of the team - but that is always within the context of helping them to see things in a different way.'

Mr Turner says: 'Twenty per cent of our time is speaking to executive directors. . .80 per cent to people on the ground. They are generally very welcoming - some of the best ideas can come from the system experts because they know how it works.'

One recent innovation has involved a senior manager from the trust or health economy being examined joining the team for their visit and then starting the process of initiating change. In Oxford, this has fallen to director of patient access for the Oxford health system Jan Elliott. 'It allows me to set some of the recommendations into context, ' she says.

One lesson from Oxford is the importance of human resources - in future visits elsewhere, an occupational psychologist will be used to tackle people issues.

So what can the team do? First, it can diagnose problems. In Oxford, this has involved a certain amount of number-crunching. It can include looking at waiting lists down to the level of the individual patient. Two external consultants, working for the team, are examining whether patients are being put on waiting lists inappropriately and whether they will come forward for surgery when their name comes up. Several factors influence this - from patients choosing private treatment or moving house, to them changing their minds and not wanting the treatment. But having 'inaccurate' waiting lists can distort funding decisions as well as causing trusts to miss targets.

Second, it can suggest some quick and easy improvements, which can be implemented by the trust's own staff.

And last, it can help the trust raise its own capability to deal with problems. This can range from pointing the way to more management and board development to broader system changes.

Which trusts should the team concentrate on in the future- at the moment it is planning visits to all 12 zero-starred trusts. But it may not have the time or capacity to tackle other trusts, nominally better-performing, but perhaps with problems which are beginning to affect services severly.And some no-star trusts are improving fast and may not need the team's input so badly.

'What I am clear about is you can't be everything to everybody, ' says Ms Jones. 'We need to stick to the knitting - we are good at diagnostic stuff, and we are good at beginning to initiate capability on the ground.

'But if we step over the line and move into sustained support, I think we will fail as a team.'

A spot of bother

Oxford Radcliffe Hospitals trust has had more than its fair share of troubles over the past four years. In September it was one of 12 trusts to get a no-star rating in the government's performance ratings: it has a year to improve.

Perhaps the most public and painful of its problems has been the independent inquiry into the Oxford Heart Centre, which was published a year ago.This concluded that the centre was 'on its knees and riven by internal conflict'.The report made a series of recommendations, which the trust committed to implementing.

Just two months later a regional team visited the trust and questioned the viability of some of the trust's services. It highlighted the problems in the accident and emergency department, which has been working under enormous pressure, leading to long trolley waits.

In response to these pressures, the trust set up a medical assessment unit to keep some GP referrals out of A&E.However, this became used as a medical admissions ward and frequently had to close.

The pressure on staff working in A&E became so great that the Royal College of Nursing threatened industrial action - an extremely unusual step.

In the past few months, the picture has been a little brighter.Morale has lifted in the A&E unit, with the RCN praising managers for their 'visibility', and a£10m refurbishment has started.This will provide a separate children's A&E department as well as improved facilities for adults.

At the last trust board annual general meeting, chief executive David Highton said the trust had turned the corner, and was in financial balance for the first time in five years.However, there were still 300 nursing vacancies and 100 beds closed because of staff shortages.