Our financial position

I am sorry there has been a gap of a few weeks in between my blogs. Since September we have launched the monthly CEO Brief and made it open to all staff. It has been great to see so many of you there – please come along if you can. They are also filmed so you can catch up here: CEO brief videos

I would like to update you around our financial position – which is not where it needs to be. There are a number of reasons for this: increasing demand on our services; the volume of medications we are using; our backlog of maintenance in estates; and the number of temporary staff we are having to use, amongst others. The Trust’s historic debts and borrowings also cause us financial pressures, as do our PFIs – the buildings which are run on our behalf by private companies.

It is without doubt that we have a far greater challenge this year than in previous years, and will require all your help to fix it. I would urge you all to be aware of this and take this into account as you deliver your services. Remember, as well as providing safe and compassionate care we also have a duty to look after taxpayers’ money and spend it wisely.

I am, however, actively seeking to change the tone about how we talk about our finances. When we reflect on messages about money, to date (and probably every year we’ve been talking about the issue) they are almost entirely negative in tone – ‘keep within budget’, ‘don’t spend on this’, ‘we can’t afford that’ and so on. It is right that we have to manage our money properly, but I believe that people are motivated by reward and positive change far more than by restrictions and central control.

As we go into next year I would therefore like to discuss with you, and ask you all to think about, how we can change this. We will definitely be thinking about incentives and how we can use good financial management, or more efficient ways of working, to provide reward and investment for staff and patients at department level, so we can directly link good practice to improvements in patient care and staff wellbeing.

If you have any ideas around this, please get in touch with me directly. This is critical to creating a culture where success breeds success.

Finally, I leave you with the example of Kelly, one of our domestics from our Brookside clinic, whom I met last week. If the non-clinical waste bins in her area aren’t more than half full, she deliberately empties them without always changing the bin liner, because she is conscious of the cost of replacing these. It is small steps such as this that together will achieve the bigger goal of financial stability as well as better care for our patients.

As always, it would be great to hear from you.



07920 071 814



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Dealing with current and future gaps in our nursing workforce

Dear Colleague,

I hope you are all well and, where possible, enjoying the summer weather and trying to get some time off. This unusually hot summer has put some additional stress on us in terms of demand for our services. Some parts of the Trust are also really challenging to keep cool; I’m really grateful for all you have done to look after each other and our patients.

I set out in my opening blog a set of priorities, one of which focused on a desire to ensure we were able to deal with the current and future gaps in the nursing workforce. That is not to say by any means that vacancies in other professions don’t cause us significant challenges, but the nursing workforce is by far the largest body of staff. Future projections for those entering nurse training nationally are worrying. We don’t have the number of nurses we would like at this moment, and with 1 in 9 posts vacant in England, this is unlikely to resolve quickly. So how do we adapt for a world where there aren’t enough nurses and we know that more qualified nurses = better patient outcomes?

My personal thoughts as to what we need to focus on:

  • How is this organisation a great place to be a nurse? Yes, being competitive on pay within the bounds of agenda for change is important, but what can we offer that is different? Access to different specialty rotations, opportunities for personal development, pathways into specialist roles and working for a Trust that has been recognised nationally for some of the innovative work we do here – we do good things, but we need to do more. Most importantly, how do we make nursing more enjoyable here: developing professional autonomy and an environment where nursing can thrive?
  • We will have to get better at managing the future supply of nursing: this will involve working with numerous educational providers and developing partnerships that bring nursing education directly into the county and our own organisation.
  • New roles – we need to accept that with not enough nurses coming through the universities we will need to look at different training routes (driven via apprenticeships) and the vocational training of higher banded support staff.
  • Some of the solutions will come through redesigning the team structures that serve wards, departments or localities. This means looking at all the clinical and non clinical professions that will be needed to work together to provide the most appropriate care. This includes therapists, technicians, clerks, pharmacists and psychologists, for example, who will all have roles to play. It is critical that these teams are designed at ward / theatre / locality level involving all members of the multi-disciplinary team around the needs of our patients. Some areas, such as the National Spinal Injuries Centre, are already forging ahead with some innovative new models.

It’s a daunting problem but one which everyone is facing; and one for which I know we have the skills and experience to tackle together. Carolyn is leading this programme and will require all of your support: if you want to help and advise us on this journey please do get in touch, we want to hear from as many people as possible.

Once again, thank you for all that you do. Please do contact me if you want to discuss anything further; thanks to all of you that have already done so.

07920 071814

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BHT’s safety culture

In my last blog I outlined some personal priorities. As a reminder:

  • Developing a safety culture
  • Hearing the patient voice
  • Getting things done
  • Transparency of decision making
  • Financial sustainability and dealing with the growth in demand for care
  • Developing the nursing workforce

I would like to discuss with you each of these in a little more detail over the coming weeks, both so you get to hear what the senior team are going to be spending their time on, but also so I can learn from all of you how we should be developing these.

Starting with developing a safety culture, I want to outline the three areas that I think are important next steps for us here:

Firstly, becoming an organisation that learns. Learning from successes and mistakes is critical to ensure they are repeated or avoided in the future. I want us to make it easier to transfer this information around the organisation beyond our traditional methods – think about what it might mean in your teams or departments.

This doesn’t only apply to clinical care either: it is equally important for management decisions, and we should be brave enough to seek feedback, celebrate when something goes well, and learn when it doesn’t.

Secondly – we need to continue to develop our culture. People who want to tell us things that are uncomfortable should be welcomed and taken seriously. If you can spare the time, watch this film from Mersey Care on how they did this, it is superb. https://www.youtube.com/watch?v=bu9yhdOegm8

Thirdly, we need to understand the complex reasons why things don’t always go well, and design systems that reduce risk, especially from human factors. This is relevant in all parts of the organisation, so I am keen to support training and development in this area – the Board will be undergoing specific training later this year, and we are looking at how we can make this available to all staff. Please get in touch if you would like support in your area.

There are some great IT programmes being rolled out shortly that will help develop our safety culture. The Board last week approved the roll out of e-observations across the organisation (hopefully by Christmas), and if you haven’t yet seen the Careflow system we are also deploying, take a look at this link (http://www.careflowconnect.com/). Dr Jeremy Drake, one of our consultant anaesthetists is leading on this so please do contact him if you wish to learn more.

Finally – the CQC have a useful checklist for all to use when assessing organisations / departments for safety. I’d encourage you to take a look:

June blog image_CQC what good looks like checklist

As always, please do contact me with any thoughts or comments, and thanks to those who have already done so.


07920 071 814

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My personal priorities

In my last blog I promised I would set out some personal priorities as CEO (in line with our existing strategy) that I have been talking through with the board and with some of you already – so here goes!

In no particular order of priority….

Developing a patient safety culture. We have really moved forward in the Trust in the 5 years I have been here about recognising and being open when we don’t get things right and sometimes cause risk to both patients and staff. But the absence of harm does not always mean the presence of safety. Our next stage is how we measure and celebrate safety and create a culture that supports learning – excellence reporting is a great example.

Getting things done. We need to make the organisation ‘work’ better and make it easier to do stuff  – rapidly spreading improvements, using quality improvement methodology to solve issues and move beyond ‘business case’ culture. This is reversing learned behaviours over some time, so we won’t always get it right, but we should call it out when it happens.

Making decision making more transparent. We should be continue to develop as an open organisation and publish how we make decisions, so you can all see and comment on the choices we make. You’ll see this start to come through the daily staff bulletins.

Transforming the nursing workforce. I’m sorry if you’re not a nurse and you feel aggrieved that I haven’t singled out your profession – but the nurses are our largest part workforce, and we haven’t got enough of them. We need to make this a great place to be a nurse, but also recognise we need to create ward and community teams that embrace different skills and professions to generate true team working – we all have a role to play in this.

Sustainability. Our largest collective challenge is the unsustainable growth in emergency demand, from both a financial and quality view. Through supporting primary care, strengthening our community services, and getting the patients to the right part of our hospitals quickly, we will solve this.

The patient voice. Do we hear it enough? Great organisations design service changes in partnership with patients, and get better results. The development of the community hubs is a great example of this.

I hope this gives a sense of my personal priorities, and what I will be focusing on: I’ll be discussing these further with you through a series of staff events in the coming weeks. Would be great to hear your views.


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CEO reflections on first week in post

[Blog post first published: 23 March 2018]

At the end of my first week as chief executive, I thought I would take the opportunity to share with you some of my early reflections on the role and how I want to approach it going forward.

Firstly, it’s really exciting and inspiring – I hope this feeling is one that I never get bored of or take for granted. The opportunity to be able to lead and shape an organisation for the benefits of our patients and staff is a privilege that was really brought home to me after I was appointed and I received ‘good luck’ wishes from many of you. BHT has tons of talented and dedicated people and, along with the rest of the executive team, to be able to serve you as a leader is an honour.

I also get the chance to work with external agencies and partners, all of whom bring an interesting set of perspectives and challenges to how we knit together as a health AND social care system. There are some really innovative changes being planned, especially in mental health and social care organisations, and we should be able to make substantial progress over the coming months in how we create a simpler and more responsive system for the local population.

It is widely recognised that there is no tougher time to be running healthcare organisations. You have put in significant numbers of extra hours; the demand for care has been relentless; and we have real challenges in recruiting the numbers of people we need. The statutory requirements of a chief executive are numerous and complex, but they can be basically distilled down to (a) keeping patients and staff safe and (b) sound financial stewardship. Being able to discharge these responsibilities is our collective challenge, and what makes the roles we do so demanding but ultimately rewarding. There will no doubt continue to be difficult decisions ahead of us: my personal mantra is that if these are made with the patient and staff put front and centre we won’t go too far wrong.

To succeed, all routes in my view lead back to how we support leadership and engage with our people – watch this space for plans for the rest of the year. Thankfully I have a fantastically supportive Chair and board, along with access to colleagues in my team, across the organisation and outside that I will be drawing on for their wisdom and experience at every opportunity.

Finally, when I walked through the door on Monday, in my new role, one of my strongest feelings was one of responsibility. This is my fifth year at the Trust; I know many of you and am proud to work for you as colleagues. I now, on behalf of the executive team and with oversight from the board, have the job of plotting this organisation’s strategic future through the myriad of challenges that will appear in the road ahead of us. There is nothing more important to me than continuing our onward journey towards being outstanding for our patients and the public in everything we do: to do so I’m going to need your help, and look forward to working with you all.

Thank you for reading this far and for your support over the past week. It is important to me that I listen to you, and that your experiences and suggestions continue to shape everything that we do. We’ll have ample opportunity to talk over the coming weeks and I’ll publish where and when shortly.

Neil Macdonald

Chief executive


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Raising concerns


My Latest vlog, which you can view above, arose out of a conversation with Trust chair Hattie Llewelyn-Davies where we were reflecting on the topic of raising concerns. This is a subject that has been of much discussion across the NHS over the past few years and, for us both, how comfortable staff feel to speak up is an important barometer of our culture and values. It is an open culture that welcomes bad news and supports staff to raise concerns that ensures we keep our patients safe.

So I’m pleased to be joined by Hattie and non-executive director Graeme Johnston to share our personal experiences of raising concerns. You will also hear from David Sines, our designated non-executive director for whistleblowing and Tracey Underhill, our new freedom to speak up guardian.

As you will see in this vlog, we understand that having the confidence to speak up isn’t easy, which is why it is important to us – and the rest of the Board – that our staff feel supported and enabled to talk about their concerns.

There are a number of different ways you can raise a concern in the Trust. In the first instance, please talk to your line manager or clinical lead, if this is not possible or you wish to raise your concern in confidence please contact our Freedom To speak Up Guardian – Tracey Underhill on her dedicated phone line 01296 316027 or 07768612590 or email Tracey.Underhill@buckshealthcare.nhs.uk.

Alternatively, you can contact David our designated non executive director for raising concerns via email david.sines@nhs.net. or any of our executive directors or refer to the Trust’s raising concerns policy which has been reviewed and is about to be re launched in September.

Please be assured you can speak up safely and I encourage you to do so in the interests of all our patients, staff and the quality of care we deliver.

What else have I been doing since my last blog:

  • Continued with the series of SDU strategy meetings, including plastics & burns and radiology, as well as my quarterly catch-up with SDU leads
  • Hattie and I met with representatives from NHS Improvement to review our operational performance. We also attended a meeting with the CEO and chair of East & North Herts NHS Trust to share what we are doing in Bucks and see if there are opportunities for shared learning
  • Work on moving to a Buckinghamshire accountable care system is progressing. I attended a meeting at the King’s Fund with Secretary of State for Health, Jeremy Hunt, and Simon Stevens, chief executive of NHS England, to discuss next steps and meet with representatives from the other 7 accountable care systems. On the same day, we were delighted to hear our bid for an additional £4.2m to improve our A&E facilities had been successful
  • Within Bucks, I chaired the ACS Board and we held a CEO and chair workshop with all Bucks ACS partners
  • I spent Feedback Friday with the community dietetics team
  • I met with the chief executive and chair of the Spinal Injuries Association
  • I welcomed our new intake of FY2 doctors at their induction, spoke to the latest cohort of our leadership pathway programme, and opened the integrated children and young people services’ celebration event
  • Caught up with Sir Andrew Morris, chief executive of Frimley Health NHS Foundation Trust.
  • Visited the clinical areas at Amersham Hospital and talked to the team about how we can address the staffing challenges in Waterside ward
  • Met with Chris Hopson, chief executive of NHS Providers
  • Welcomed Jim Mackey, chief executive of NHS Improvement, and his team – including the Prime Minister’s special advisor for health – to Wycombe Hospital where we were able to showcase cardiac, stroke, MuDAS and community hubs                                 visit group

But it’s not been all work and no play. I was invited to the High Sheriff of Buckingham’s summer reception and as you can see from the picture, had great fun at the National Spinal Injury Centre’s family fun day.


All that remains for me to say is to those of you taking a well-earned break over the summer I hope you relax and to those of you working, a very big thank you.


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Bringing the Accountable Care System to life

It’s been a hectic but successful few weeks since my last blog, with a particular highlight being the announcement of Buckinghamshire Healthcare NHS Trust as one of eight accountable care systems (ACS) in the country. I was proud to be able to talk about what this will mean for us at the Health & Care Show at the Excel Centre in London, Europe’s largest integrated health and social care event, building relationships between commissioners, providers and suppliers.

Lou Patten, accountable officer of our Clinical Commission Group, and  I led an accountable care system  joint working workshop which was attended by a cross-section of employees from Buckinghamshire Healthcare NHS Trust, Oxford Health NHS Foundation Trust, Aylesbury Vale  and Chiltern Clinical Commissioning Groups, Fedbucks  (a professional body representing GPs), Buckinghamshire County Council and South Central Ambulance Service. The purpose of the session was to develop shared working and accelerate our plans. It was great to see teams from across the system come together.

I was delighted to welcome Lou, and her deputy, to our executive management committee so that we could discuss how we can make it easier for teams from Buckinghamshire Healthcare NHS Trust and the Clinical Commissioning Groups to work together – vital as we become an accountable care system .  We have agreed to hold regular joint executive meetings – a clear case of taking a different approach to strengthen our working relationship.

Community hubs group

Accountable care systems are all about how we engage and serve our local communities and I was delighted to welcome more than 100 members of the public to our successful open day at our community hub in Marlow where we talked to them about the improvements we are making to healthcare in their local community.

Here are a few more highlights from the last couple of weeks.

  • Visited clinical areas at Wycombe, including the stroke ward, ward 8, the paediatric and neonatal areas and Loakes theatres. Staff were doing a great job trying to keep patients cool in extremely hot weather.
  • Attended the Quality Committee meeting at Stoke Mandeville Hospital, followed by a morning in the trauma theatre and the afternoon in the neonatal unit. Both teams were great examples of how every member of the team is valued and is of equal importance and the CARE values being displayed through our compassionate leadership.
  • Met with GE Health. This was an exploratory meeting to see how we can work with commercial partners to promote health information, increase patient involvement and develop new products.
  • Leaders from across the system attended a BHT Way event where we talked about the importance of our people and developed plans to improve staff engagement and shared best practice. Nicole Ferguson from Wrighton, Wigan & Leigh NHS Foundation Trust talked about her Trust’s experience in improving staff engagement and the lessons they have learnt.
  • Led the sexual health and stroke & neurology SDU strategy meetings.
  • Spent Feedback Friday in Children’s Therapies at Wycombe.
  • I, Carolyn Morrice, Tina Kenny and Liz Hollman met with regional Care Quality Commission Leads to discuss the progress we are making against our strategic priorities and our ambitions to move from requires improvement to outstanding. The Care Quality Commission told us about the changes to the current inspection regime.
  • Visited the Shaw clinic to meet with Jackie Sherrard and other members of the team. Significant progress has been made and Jackie’s leadership has made a significant difference.
  • Invited to attend an awards ceremony at Amersham School. I spoke to the young people and their parents who attended about the importance of resilience and being focused on your goals. I was also delighted to present awards to those who had achieved excellence.
  • Last week I spent time with A&E, Ward 10, Theatres, ICU, Labour Ward, Neonatal Unit, Ward 17, 16B, 8,9, 5,6,7,4 and Ward 3 at Stoke Mandeville Hospital to test staffing levels and see the challenges you face. As a result a briefing has been circulated to all clinical teams to address the issues that were raised and we will continue to monitor the situation.
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