TRANSFORMATION OF THE LUTON & DUNSTABLE HOSPITAL
STEPHEN RAMSDEN, CEO
I’d like to tell you my story of change for the L&D – where we need to take our hospital and
how we should work together to get there. It is told from my personal perspective as the
CEO for the last nine years and it will need your perspective to be complete.
It describes where we have come from, where we are today, why we need to transform,
and my personal vision for the L&D. I will lay out what this means in practice, what
changes we need to see and how we are going to make them happen. How we can
overcome the challenges we face and, very importantly, what I’m asking of you and what
you can expect from me. By the end of this story I hope you will understand what I believe
success would look and feel like and that you will share your views and feedback with me,
to turn this from my vision into our vision.
Where has the L&D come from?
Over 10 years ago, the L & D had a poor reputation, it had achieved national notoriety over
the bugging of a consultant’s telephone by the management, symbolic of the breakdown in
relations between the Trust and the Doctors (and other staff). I arrived 9 years ago and at
my inaugural talk to Doctors in the COMET Centre I described the L&D as a sleeping giant
that we would soon awaken. We had big financial problems in those early days and the
culture was not one of putting quality at the top of the Trust’s priorities.
What did we do? We embarked upon a 5 year strategy that we called ‘Building Pride in
the L&D’. We decided to put the hospital on the map locally, nationally and internationally.
We appointed a Director of Improvement and a Change Team to help us. We created a
small Communications team. We built trust, respect and strong relations with the Doctors.
And we tried to improve the working lives of all staff. In more recent years we have
engaged PCTs and others in jointly setting our transformational goals. We have been
involved in the international ‘Pursuing Perfection’ programme and are truly seeking to
make improving the quality of services our highest priority.
Where are we today?
We are proud of the L & D. Today we have an excellent reputation based on some
outstanding achievements. Let me list just a few. We have focussed on patient safety
with real results. We have reduced our hospital standardised mortality rate from 11%
worse than national average to 10% better than national average over 3 years. Our
stillbirth rate has been brought down to the national average, having been one of the
highest in the country. This is the lowest it has been in 10 years. Some years ago I met
with 40 Asian ladies in the Gar se Gar Community Centre in Luton. They had all had
stillbirths. They told us, through interpreters, about their harrowing experiences accessing
healthcare, including our maternity unit. I was moved by their stories. So too, were the
two obstetricians and PCT CEO who were at this meeting. The experience shifted our
attitude. We started to talk about avoidable stillbirths, we treated each as a serious
untoward incident, we gave mobile phones to interpreters so they could be available 24
hours a day. We introduced new systems to manage ladies with higher risk pregnancies.
It was my first real local experience of the power of the patients’ story.
We now have excellent relationships with the Doctors, and indeed with all staff groups.
Doctors are leading the Safer Patients Initiative and are more actively involved in the
leadership agenda, working in Clinical Directorate ‘Partnerships’ with General Managers.
Today our finances are in surplus and have been for 8 years running. This has given us
some freedom, some headroom, to give a really high profile to going further than national
targets. For example, in cancer waiting times, on patient safety and on pioneering work
towards the 18 week waits targets.
Today we are seen as a high performing hospital, a national leader in patient safety
(achieved through being the England pilot site in the Health Foundation’s Safer Patients’
Initiative), we achieved Associate Teaching hospital status 4 years ago and Foundation
Trust status in 2006. We regularly receive good local and national press, particularly for
our work on patient safety.
On reputation, it struck me how far we had come when we were runners up last year in the
Health Service Journal Acute Trust of the Year Award.
We are proud of the L&D.
Why do we need to transform?
First, while we have made great progress on building pride in the L&D, we still have much
more to do to achieve our goals of having no needless deaths, harm, suffering or pain.
(We call this the ‘no needless’ framework). We still have avoidable deaths and we have
some way to go before we can say our death rates are the lowest in the country. We are
not yet providing the care and treatment that is reliable enough and one reason for that is
the lack of standardised approaches amongst our clinicians.
Second, we are an ambitious hospital and want to go even further, way beyond national
targets. We’ve shown that with our Cancer Waits Stretch Goals. Nationally, only cancer
patients referred by GPs as urgent 2 week cancer referrals are counted in the 62 day
maximum wait from referral to treatment, this represents only 25% of cancer patients. At
the L&D we count ALL cancer patients, irrespective of route in and are consistently close
to achieving this 62 day ‘stretch goal’. It was one of our Non-executive Directors who was
dismissive of the national cancer waits target at a Board meeting 2 years ago and
encouraged us to be more ambitious for our patients.
Thirdly, the NHS is changing at a rapid rate and if we don’t move fast, we’ll fall behind.
The impact of patient choice, private sector competition, payment by results, service
reconfiguration (hospital to hospital, hospital to primary care) all needs to be managed
And finally, if we don’t get the basics right, then we will struggle to achieve our
transformational goals, we will be distracted into short term survival, we cannot allow this
to happen. Getting the basics right means we must improve the patients experience, too
often patients are unhappy about elements of our care, they have not been treated with
dignity or respect or have not been given adequate information about their treatment.
A transformational vision for the L&D
The L&D should lead the NHS in patient safety. We’re good, let’s become great. ‘The
programme we have embarked upon in the Safer Patients’ Initiative is more ambitious than
any being attempted elsewhere’. (Don Berwick, President, IHI Boston). 29 improvement
initiatives simultaneously implemented across the L&D, (the hospitals involved in the USA
Save 100,000 Lives campaign used a maximum of 6 initiatives). Our initial objective of
reducing errors by 50% has been achieved, let’s go for zero errors now.
So what does success look like?
For L&D patients, it means no needless pain or suffering, harm or deaths; no
needless delays; no helplessness or inequity. It means patients who are empowered
to shape their own care, as well as to help us improve services.
For L&D staff, including non-clinical staff, it means continually improving and
innovating, having pride and high morale. They will need support, training and
development to help them achieve their best.
For the NHS, we offer a real working hospital that is a safe, reliable hospital that sets
the example and helps others get there.
What does success look like?
To fulfil our vision of leading the NHS in patient safety we need to deliver world class
safety outcomes and we need to put the patient at the centre of our continuous
We will need to:
1. See Patient Safety being the Number One Strategy for the L&D. It is more
important than targets.
2. Achieve a more equal partnership between Doctor and Patient in their relationship.
We can build on the success of the project involving patients with Head & Neck
Cancer, who, with staff, have ‘co-designed’ over 40 improvements in their
3. Doing all the important care processes in a standardised, evidence based,
protocolised way (ideally with the benefit of new Information Technology – Clinician
Order Entry systems).
4. Having a full set of measures to monitor progress against our ‘No Needless’
5. A culture of all staff wanting to continuously improve their service. Many of these
staff will be capable of driving improvement work/projects – this applies to all
managers, ward sisters, all clinical heads of department and many doctors.
6. Helping other hospitals improve patient safety through our involvement in Phase 2
of the Safer Patients Initiative, the East of England SHA Patient Safety Forum and
through other national and international opportunities.
To support our vision of leading the NHS in Patient Safety we need to ensure the L&D is
Fit For Purpose in the 21st Century NHS. We will need to:
1. Move towards serving a population of 500,000 in a centre of excellence for Beds &
Herts, from the current population of 300,000 from Luton & Dunstable.
This Strategic Direction is already supported under the Beds & Herts ‘Investing In
Your Health’ strategy. More patients from Hertfordshire will see the L & D as their
local hospital following the changes at Hemel Hempstead Hospital. We will create
more specialist centres for larger populations, especially for cancer, cardiac, obesity
2. Providing Care in the right Place. We will do this by reducing avoidable admissions,
by helping GPs manage patients with chronic conditions in primary care and by
improving access to diagnostic services for GPs.
Again, this is a fundamental part of ‘Investing In Your Health’.
3. Manage emergency and elective patients separately within the L&D. This includes
separate facilities and increasingly applies to the workforce so the clinical teams
can concentrate either on the needs of the emergency patients or the elective
patients, but not on both at the same time.
This will also help in our vision of improving patient safety, patients experience,
reliability and efficiency.
4. Improve the patients experience by getting the basics right and seeing the annual
patient survey results in the top 10% in the NHS.
Getting the basics right means addressing the concerns that patients flag up in the
annual survey – information and communications from clinicians, waits within the
hospital (for a bed or for a consultation), noise at night, car parking. It means
improving communications with GPs about their individual patients, timely discharge
letters for example. It means having accurate ‘live’ patients data that can be used
to aid prompt, safe, clinical decision making.
How are we going to do this?
We will create new cross cutting arrangements to lead on the implementation of some of
the main themes in this story of transformation:
Leading the NHS in Patient Safety
Improving the experience for both patients and staff
Making the L&D Fit for the 21st Century
Improving the Delivery, including the creation of Strategic Business Units
(SBUs) We have just started to implement SBUs. It will require a review of our
organisational arrangements and a devolution of autonomy with SBUs having
income as well as expenditure. The SBUs will also create long term strategic plans,
seek to improve clinical outcomes, safety and patient experience.
Each theme will be led by two Executive Directors who will now create plans to ensure we
fulfil our transformational goals in these areas.
We will also now work closely with our directorate partnerships to focus on specific
initiatives to deliver this transformation.
The principles that need to be incorporated in directorate partnership initiatives and in the
delivery of the above themes are:
Truly put patients at the centre of our improvement efforts. Follow the examples in
the ‘No avoidable stillbirths’ project and the ‘Head & Neck Cancer Services’
partnership by empowering patients and making partnership with patients the norm.
Having even more doctors engaged and leading improvement work. There will be
opportunities for all staff, but unless doctors play a key role, the transformation will
Integrate the key components of patient safety, patient/staff experience and
efficiency/productivity in our improvement initiatives and service re-design generally.
Attention to getting the basics right.
Measuring and tracking our progress against what we’ve promised to deliver. This
will require a new Information Strategy, better information and better use of
information to improve services.
Strengthen our improvement skills, building increased capacity for change. This will
be required across all staff groups and managers.
Build a continuous improvement culture in all staff.
Utilise the principle of ‘earned autonomy’ for example, in the creation of Strategic
Business Units. More freedoms will be delivered to SBUs that demonstrate they can
take accountability for devolved decision making.
What are the 3 main challenges we face?
1. Financial constraints – we will never have enough funds to do everything we want
to do. Our PCTs have big financial deficits. The NHS will receive less generous
2. The agenda is too large and ambitious to do everything properly. We do not have
the management capacity and capability to deliver it.
3. Resistance from some staff. Whilst leading the NHS in patient safety is likely to
gain much support, some of the other components of this transformation may be
resisted. Empowering patients, standardising care processes, improvements in
efficiency and productivity may not always be supported.
We can overcome these challenges by drawing on our past successes of ‘Building Pride in
the L&D’, maximising the use of Foundation Trust status freedoms, our strong partnership
working between doctors and managers and above all, our excellent and committed staff
and prioritising our efforts by stopping to do some things. Strategic business Units will
also provide incentives to maximise income and efficiency.
What am I asking you to do?
I am asking for your help. If you have something to add to the vision, an idea for
improvement, tell me. Be proactive. Come not only with problems, but solutions.
Of the Top Team – firstly I need your help in getting this transformational story right for the
L&D. Then I want you to create your own version of it and get your own teams on board
with it. Then you will need to visibly lead its implementation. Some of you will need
personal development, for example in improvement skills.
Of the Doctors – we need you to be even more engaged in leadership and improvement,
especially to improve the safety of patients. We need to free you up, find ways to develop
and support you. The partnership work with managers needs to be further developed.
The new approach to partnership with patients needs your support.
Of Managers – I want all of you to develop improvement skills, I’ll take a personal interest
in helping you achieve this. You need to carry on the partnership approach with doctors
(and other clinicians). You need to get your own teams on board with the transformational
story, ensuring that patient safety continues to improve. You need to help us get the
basics right, make us fit for the 21st century NHS. Ward Sisters and Clinical Heads of
Departments, in particular, have a really important role in this.
Of all Staff – I want you to seek to continuously improve your service. We need to get the
basics right and become more customer focussed. Non clinical staff have as much to
contribute to this transformation as clinical staff. We are all here to improve patient care. I
hope you see the vision of Leading the NHS in Patient Safety as one that inspires you
and maintains your pride in the L&D. Tell this story to your family and friends. Talk up the
What can you expect from me?
I will tell our story with passion and with commitment to make it happen. I will seek to
inspire people to the transformation that is going to take place at the L & D. I will show
visibility in leading the transformation through leadership walkabouts and through listening
to staff and patients. I will also hold all of us to account and challenge staff to uphold the
values and aims contained in this story. I will support my team to help them deliver this
And finally, what will success look and feel like?
I know we will have succeeded when:
Our hospital standardised mortality rates are the best in the UK and we are emulating
the achievements of the best hospitals in the USA, e.g. no avoidable infections.
We all feel pride, ambition, humility, passion.
And when a patient stops me on a safety walkabout and says – ‘I’ve come 50 miles for
treatment here, because I was so impressed with your record on patient safety. I’ve felt
safe and cared for at all times. I’ve been completely satisfied with my experience’, then I
will really know we’ve succeeded.
Luton & Dunstable Hospital NHS Foundation Trust