How staff at a 'failing' trust are leading its turnaround

Innovative leadership development programmes are usually regarded as an investment in the future of an organisation, but an innovative east London scheme has framed its leadership development rather differently − as a practical way of solving a real and immediate problem.

‘Challenged trusts often have problems with maintaining a conducive training environment and a common response is to remove training status from them’

Barking, Havering and Redbridge University Hospitals Trust has not had an easy time recently. Serving a diverse and largely deprived community, the trust has been the subject of intense regulatory scrutiny for over four years. During this time, significant and persistent concerns have been raised about the quality of patient care in a number of departments.

Under new management, progress is being made but the trust has experienced challenges familiar to other organisations labelled as “failing”: poor staff morale, problems with recruitment and a high proportion of disengaged employees.

Under these circumstances, the regulator often demands a trust seek out external expertise to advise on a programme of change and service improvement. Unfortunately, this too often fails to address fundamental problems.

Whether the outside experts are local commissioners or management consultants, the people they need to influence − the frontline staff − tend to distrust their intent, their commitment and their advice.

And so the trust, working with Andy Mitchell, the medical director of the then strategic health authority, and Fiona Moss, then postgraduate educational dean, came up with a new solution.

Solutions from within

Challenged trusts often have problems with maintaining a conducive training environment and a common response is to remove training status from them. Working together with postgraduate education partners, the trust designed an innovative fellowship programme for a group of clinical leaders who had recently completed their higher professional training.

‘Participants reported that their confidence grew as a result of the programme, they felt more empowered to lead change and more resilient to deal with setbacks’

Ten of the 22 fellows, comprising doctors, nurses and midwives, were appointed from outside the trust initially on a 12 month contract, dividing their time between a clinical commitment and a responsibility for leading quality improvement activities. The other fellows were appointed from within the trust with a similar division of responsibilities.

The result was no overall loss of clinical service time and a new improvement resource for the organisation, with the fellows leading on a range of quality improvement projects, some of which were specialty specific and some addressing more generic improvement challenges.

A professional development and support programme, supplemented by individual coaching, was established for the fellows to help them strengthen their individual leadership, improvement and change management skills. The fellows were also matched with one or more established senior member of staff in the trust, who acted as mentor and who rapidly became part of what was often a vibrant mutual learning set.

Sixty members of staff participated in the scheme, which launched in March 2012. A pragmatic evaluation of the scheme was carried out by research institute RAND Europe, working with Improvement Science London, a collaboration between the London Academic Health Science partnerships, which aim to promote and embed a more evidence informed approach to organisational change.

The emphasis was on more than simply understanding whether and how the scheme worked; indeed, the evaluation was designed as part of the problem solving process.

Team interactions

Participants interacted with the research team in workshops to explore how a bounded intervention involving only a small proportion of the staff group might have an impact on the wider culture and performance of the trust, and to understand underlying assumptions and complex interactions between the scheme’s inputs, activities, outputs and outcomes.

The combination of the three main features of the initiative − the development programme, learning by doing improvement projects and the interaction with the evaluation team − led to a number of positive changes. Participants reported that their confidence grew as a result of the programme, they felt more empowered to lead change and more resilient to deal with the inevitable setbacks associated with any large change programme.

While some of the trust staff not directly involved in the scheme remained sceptical, most saw it as one of the more successful of the “turnaround” initiatives in the organisation.

‘Unlike so many attempts to intervene in challenged organisations, the scheme has left a lasting legacy’

Fellows being on the ground, providing services and working alongside their peers, made a big difference, primarily because they were regarded as more credible by their peers than external consultants. So too did shared learning between fellows and mentors, both of whom were long term employees of the trust, and new fellows who brought fresh insights and additional skills to the organisation.

Supported by the executive team, the time and space provided by the scheme enabled participants to think differently about their work. This was key to the scheme’s success, contrasting markedly with the “heads down and get on with it” approach so prevalent in challenged organisations.

Permanent change

Unlike so many attempts to intervene in challenged organisations, the scheme has left a lasting legacy. Two of the fellows appointed from within the trust have new roles and responsibilities as a consequence of the investment in their personal development and several of the mentors mentioned how the scheme had helped to revitalise their own professional practice.

Three of the fellows appointed from outside have been recruited by the trust to additional fixed term or permanent staff positions − a significant achievement given the challenges of recruiting good staff to struggling organisations. And the board of Barking, Havering and Redbridge Trust has agreed to fund further cohorts of fellows, building on the learning from the first scheme.

The success of this initiative suggests one way local education training boards, supported by Health Education England, could actively help challenged trusts in the future. This is leadership development at its most practical.

Martin Marshall is professor of healthcare improvement at University College London; Celine Miani is an analyst and Ellen Nolte is director, health and healthcare, at RAND Europe; Mike Gill is medical director at Barking Havering and Redbridge University Hospitals Trust. Thanks to Sonja Marjanovic at RAND Europe and Samantha Miekle at Improvement Science London for their contributions to the evaluation of the initiative.