Following the first debate held in the series 'Daring to ask', which is jointly organised with the Nuffield Trust and the NHS Confederation, we sat down with Dr Keith McNeil.
Dr McNeil is the former chief executive of the Cambridge University Hospitals NHS Foundation Trust. In 2015, the Care Quality Commission rated the main hospital there, Addenbrooke's - a teaching hospital - as inadequate and Dr McNeil resigned.
In this interview, he talks about his time as the chief executive of Addenbrooke's, what he thinks about the CQC's finding and gives advice to other chief executives who may find themselves in similar situations.
When I first got the job at Cambridge, I was ecstatic. I was really touched to have been approached in the first place and didn’t really think I would stand much of a chance getting the role. But, I was ecstatic. It was a dream job for me as a clinical academic and as a CEO to come and work at Cambridge University at such a prestigious hospital where I had worked as a clinician. It was a dream come true.
It was a bit of a body blow, I have to say, when I resigned. But I resigned for what I thought was the right reason, which was around my value set and having to compromise that because of the way the system was behaving and what was expected of the hospital in ‘special measures’. I don’t have any regrets about that. I enjoyed my time there immensely. I’d do it all again – it was hugely challenging, sometimes just fraught with difficulty, but the people there are just fantastic. They just inspire and energise. It was a wonderful experience.
The Care Quality Commission (CQC) rated Addenbrooke’s hospital services in Cambridge as inadequate in 2015. What do you think about the UK’s system of hospital inspection and regulation?
Of course, the CQC have their own peculiar way of assessing things and coming up with an answer. My point was that it was unfair and unjust, and certainly not a reflection of reality to say that Addenbrooke’s was inadequate. And, in my view, under no sensible use of that word could you describe that hospital as ‘inadequate’ because of the outcomes that patients received.
If you went in to Addenbrooke’s hospital, you had less chance of dying, less chance of getting an infection, less chance of getting a medication error, less chance of tripping and falling than just about anywhere else in the country.
We had had no maternal deaths in childbirth despite extremely complex pregnancies for over eight years. We also had the lowest stillbirth rate in the country.
Cancer outcomes were as good as anywhere in Europe for many of the major cancers. And the list goes on and on and on and on. If you had a liver transplant, ten-year outcomes are better than anywhere in the country.
So, to describe that as ‘inadequate’ seemed a little unfair and unjust, but the way that they do their matrix – it just happened to come out that way, for reasons best known to them.
Do you think your speaking out about the Care Quality Commission has changed anything?
My speaking out? No, I don’t think so.
I think that there are probably a lot of people who agreed with what I said. A lot of people came up to me and said that they were really pleased that I stood up and said what I did and to please keep saying it. But has it changed the CQC? I don’t think so.
I think there is a bureaucratic mind-set that sits outside of providers and sits outside the real delivery arm of health care. And they operate in a parallel universe. They operate in an alternate reality.
During your time at Addenbrooke’s, was there any moment where you felt like you were losing control of its management?
People often said to me ‘oh, well you run Addenbrooke’s’, and I would say to them ‘well, I don’t really run Addenbrooke’s. It’s too big and too complex for any one person to run’. My role, as I saw it, was to setup systems that enabled it to run effectively. Particularly, to give the resources that the clinicians needed on the ground to look after the patients really well – which, I have to say, they did.
I never felt, going into the hospital, that I ever had control over everything because health by its nature is an unpredictable science. And things happen in health that – even with the best of intentions and the best process and the best setup – are unpredictable. And, of course, we have no control over the demand. It was a question of juggling lots of different balls all the time, and trying to get a balance between those.
Previously you’ve referred to Addenbrooke’s as ‘an extremely expensive nursing home’. What do you mean by that?
I’ve said this a number of times. When I was there – and just the other week – we had over one hundred delayed transfers of care (DTOCs) in the hospital. So we could be described as either a residential or full nursing home. We were looking after hundreds of people on a month-by-month basis, who could have been looked after more effectively in the community.
And, of course, we were running that with a tertiary, academic overhead, which adds on costs even to what you would pay at a district general hospital (DGH). It was a very expensive use of a very precious resource, which are our acute beds.
This came about for a number of reasons. Firstly, Cambridge is a buoyant economy. So, nursing home beds are not freely available. People can afford to pay for them privately. That means the bargain-basement costs that the council wants to pay just isn’t enough of an incentive for the nursing homes to open or give over the number of beds needed. There was a lack of beds to send patients to.
Secondly, sometimes it was a lack of resource. Social care budgets, as we all know, are being cut right across the country.
And when I had arrived, there was little in the way of interaction between acute providers and community services in a very effective way. It was all very siloed.
Do you think the challenges you were facing at Addenbrooke’s were unique or symptomatic of wider systemic problems?
What I would say is that every hospital – every health economy – is unique in some ways. And Cambridge was, by everybody’s admission, in the middle of a very challenged health economy – one of the most challenged in the country. The DGHs that we have around us, that feed in to Addenbrooke’s, were also very challenged in terms of both targets and funding. There was a big problem for us as a whole health economy – so, in a way, we were like a canary in the birdcage and we always were going to be.
And we had one other thing that came along, which was that we needed to replace our PAS – our patient administration system. We had to go and launch a very expensive hardware replacement right across the hospital. It was £200million. We made that decision over a five-year period, in fact before I got there, but implementing it then when austerity hit made it very hard. That was an additional challenge, and I’m concerned that now other trusts – quite rightly – are going to stand back and ask: ‘Can we afford to do that? Is it viable to do that in this current climate?’
Do you have any advice or messages for other chief executives of hospitals who may be struggling with similar issues?
First of all, it’s a fight worth continuing. As long as you can stay in the game, stay in the game.
The second thing is that it’s all about people. It’s all about relationships and influence and working with people and getting the system to work together.
And fundamentally, the reason that we’re here – the reason all the bureaucracy exists – is so that clinicians can sit down with patients and provide effective health care. Focus on that.
As I said when I first arrived at the hospital: ‘I’m happy to be flayed for finances, I’m happy to be flayed for corporate issues. I, however, will not be held up for patient outcomes, which are going to be the best in the country.’ That’s what I set out to do and that’s what I did. That’s where I stand.
Figure out what your values are, draw your lines in the sand and don’t cross them.
In a recent debate you participated in, jointly convened by the Nuffield Trust and the NHS Confederation, we asked ‘Is the NHS on the brink of fundamental change or collapse?’ What’s your verdict?
I believe that the NHS, and most health systems really, are always on the brink of some sort of change. Fundamental change? No.
What have we heard? The latest call is for more ‘grip’ on providers. More grip is going to do nothing but strangle the system even more than it is now.
There will be no fundamental change. There’s still no extant leadership of the NHS. We’re still over-burdened with bureaucracy, with regulation, with inspection, with commissioning that doesn’t do what it should be doing. So, it depends on where you sit – but I can tell you as a clinician on the front line, that we are well over the brink of collapse.