St. George's University Hospitals NHS Foundation Trust is a major teaching hospital in South West London. It provides specialist hospital services to a population of two to three million people across many specialities. Turnover is roughly £840m and the Trust employs over 9000 staff. Roughly 700,000 outpatient appointments are undertaken each year.

Challenge

This major teaching hospital was facing up to a huge turnaround situation. Financial, quality and patient safety issues were all impacting on overall performance and care.

Its sprawling outpatients department needed some urgent fixes, serious stabilisation and improvement. It also needed to develop a sustainable long-term future as an effective service.

Morale amongst services and outpatients support staff was low. Previous change efforts had not gained traction or delivered results. A negative culture had unsurprisingly taken hold, including attitudes towards external consultants. Along with a matrix management system that confused accountability, it meant a programme to change poor and inconsistent operational processes, let alone start major transformation, was seen as a massive challenge.

Approach

We know that sometimes turmoil can also create a unique window for change. While the impetus, motivation and drive must come from within, as a consultancy we could firstly bring clarity and focus to a complex programme. And vitally, to take on the difficult tasks and deliver quick wins alongside the key managers and influencers we needed to bring on board for the big tasks ahead.

Rapid initiatives were put in place. Firstly, a campaign to reduce a very high level of missed appointments (DNAs), which cost the Trust millions of pounds, and further exacerbated waiting times. Secondly, a restructure and cultural change initiative to improve a dismal booking centre. Arduous but essential work to rationalise and refresh clinic templates. And finally, a challenging patient-safety driven series of clinic moves within and to outside the main hospital, as an urgent CQC inspection requirement.

At the same time, we began purposeful engagement across the piece. Identifying and encouraging clinical and operational leaders, going to where people were, and clearly explaining the challenges and providing opportunities for staff to be listened to. We also engaged through other mechanisms; large events with clinical staff, administrative staff, patients, commissioners and board members on the same table, design workshops, regular updates, team meetings, meeting staff in their team meetings, and open stand-ups.

We went outside the building. Stakeholders were wide and varied and we thrive on forging partnerships with aligned goals. In a first for the Trust, we invited CCG commissioners into early thinking and planning, and went directly to GPs and patient groups, often at hostile meetings. Again, we listened and provided meaningful opportunities to engage through co-design, not just describing poor experience and helping admire the problems!

This engagement created the basis for ongoing conversation around, the vision and commitment to undertaking the changes required. It created the culture shift needed to support co-design of a future target operating model, which would form the blueprint for future services and aid the shaping of a roadmap for the changes needed over the following years.

We used agile approaches for many of the changes to ensure the pace and energy from engagement was carried forward into delivery. These iterative changes brought early benefits, but also allowed us to adapt in the rapidly changing situation.

What happened?

Initial impact was vital in boosting morale, confidence and credibility for us, the Outpatient Department management team, and the Trust’s evolving programme teams. Results over the first year included:

- Reducing DNAs by around 5% - with 2000 more patients able to see specialists every month.
- Rebuilt 60% of all clinic templates, deleting around 5000 redundant templates and eliminating the 6-month template build backlog.
- Booking Centre performance improved dramatically, with calls answered within 60 seconds rising from 13% to around 90%, resulting in 7000 fewer abandoned calls each month.
- Successfully lifted a regulator warning related to congestion and fire safety within 3 months. This was achieved by reducing footfall by 15% in the main outpatient area.
- Moving 70,000 appointments per annum into more suitable community settings.
- Reducing face to face follow up appointments in one speciality by 4000 per annum, either through replacing with virtual appointments or by removing unnecessary follow-ups.
- Codesigned, with a wider range of stakeholders, a Target Operating Model for Outpatient support services.
- Improved finances by £5m per annum.

People had strong alignment across the organisation to a joint vision that they helped develop. This vision was laid out in more detail in a Target Operating Model, developed through engagement with patients, staff, clinicians and senior managers.

The process to shape the vision and Target Operating Model also shifted culture to be more inclusive, clinician-led and patient-focused. It also helped to establish much closer relationships with external agencies, patient groups and commissioners.

Our role was to lead, coach, steer and advise where needed.

Margaret Pratt, Director of Finance said:

During one of the most challenging turnarounds I’ve been involved with, the initiative to streamline and transform the outpatient service managed to engage people and drove real, sustainable, culture change.