How Covid turned flagship NHS 'super trust' into worst in the country

How Covid turned flagship NHS 'super trust' into worst in the country
How Covid turned flagship NHS 'super trust' into worst in the country

Before the pandemic, the Manchester University Foundation Trust (MFT) was on the up.

It had been three years since the completion of its “super-merger”, which brought 10 hospitals and two community services all under one organisation in a multi-million-pound deal, transforming it into the largest trust in England.

Cancer patients under MFT’s care were more likely to begin treatment within a month compared to the England average, and three-quarters of patients on its waiting list were starting treatment within 18 weeks - against a target of 92 per cent.

But then Covid-19 hit. Operations were cancelled, non-urgent treatments paused and hospital beds filled up with Covid patients.

The worst of Covid is now behind us - NHS England last week declared the virus no longer a national incident - but for the juggernaut that is MFT, returning to normality has been slow.

The trust now ranks as the worst out of all NHS trusts in England for its overall performance against key NHS targets, according to Telegraph analysis. More than 200,000 people are waiting to start treatment, and fewer than two-fifths (39 per cent) of patients are now starting treatment within 18 weeks.

Cancer patients are almost four times more likely to be waiting over a month to start treatment compared to the rest of the county. Across England, 8 per cent of patients are waiting longer than 31 days to begin treatment, compared to 28 per cent under the care of MFT.

Meanwhile, it has the highest number of “long waiters” with  969 patients waiting longer than 18 months to start treatment. The trust missed the NHS’s pandemic recovery target to clear these long waiters by April.

By comparison, MFT has more patients waiting longer than 78 weeks for treatment than the whole of London, where 907 patients were waiting this long.

Last year, the trust also experienced issues with its waiting list data after installing a new electronic patient record system, which meant it paused reporting its figures for several months. It is not yet clear if these issues would have impacted its elective performance.

In recent board papers, trust bosses blame the impact of strikes, the continuing impact of Covid, and staff sickness levels for its inability to get back on track post-pandemic.

Yet, arguably, these are issues all trusts across the country have had to contend with in their recovery. Industrial action by health unions has resulted in more than half a million appointments and operations being cancelled across England.

During the most recent junior doctors’ strikes in April, MFT had the third highest number of staff absent as result of the action, 2,940, with University Hospitals Birmingham, 3,012, and Nottingham University Hospitals, 2,975, just narrowly ahead.

Between July and December last year, MFT saw an average of one in fifteen (6.8 per cent) working days lost due to sickness - the seventh highest across 139 NHS acute trusts.

This increased to 8.1 per cent in December, exceeded only by Liverpool Women's NHS Foundation Trust (8.95 per cent) and Blackpool Teaching Hospitals NHS Foundation Trust (8.13 per cent).

The merger, which resulted in a super trust with an income of £2.5 billion and around 28,000 staff, was expected to improve outcomes and services for patients.

Plans to create the super trust came out of a review, commissioned by Manchester Council, led by Sir Jonathan Michael - a former NHS hospital CEO. Sir Jonathan's review insisted patient care would improve at the hospitals following the merger, but admitted it would be costly initially.

Jeremy Hunt 'concerned'

The deal was viewed at the time as a key part of Greater Manchester's devolution project.

NHS Improvement (which has now been brought under NHS England) also supported the plans. It said at the time it was "supportive of what the parties are trying to achieve for patients in Manchester," according to documents submitted to the Competitions and Markets Authority.

"The strategy could generate significant improvements to the local health economy, and we find that the management teams at the organisations are very committed to achieving this," the body said.

Jeremy Hunt, who was health secretary at the time, had originally expressed concerns about NHS trust mergers.

Speaking in 2013 about the checks and balances on the process of grouping trusts he told a Commons health committee hearing: “It is a concern to me… I want to make sure that they properly consider the benefits [of mergers] and also that it doesn’t take too long.”

Sir Mike Deegan, one of the architects of the NHS Plan in 2000, spent more than 20 years at the helm of MFT and oversaw its landmark expansion in 2017.

It went on to acquire a further hospital, North Manchester General Hospital in April 2021. Manchester Royal Infirmary, Altrincham Hospital, Trafford General, and Royal Manchester Children’s Hospital, are among the hospitals under the trust’s umbrella.

The reorganisation process was expected to cost at least £3m, but was proposed to benefit patients by providing greater access to specialist care, as well as more “timely and effective care” through sharing capacity and resources across the group.

Recent board papers reveal the trust’s financial “challenges”, including operating in a deficit, and confirmed it is developing a “multi-year recovery plan” to address this.

In the year to January, it delivered a deficit of £13.2m after predicting a “worst case scenario” of a £50.8m deficit in November. The trust said it has set a break-even plan for this year.

Sir Mike wrote to Steve Barclay, Health Secretary, in January warning that delays to the Government’s new hospitals plan was costing £13m a month.

He noted a recent ceiling collapse at North Manchester General Hospital forced its theatres to shut down for six weeks impacting hundreds of patients waiting for treatment.

One senior NHS source questioned whether the drive to group together hospitals into these so-called ‘super trusts’ was, in fact, a “fool's errand” and that the size of MFT could be hindering its pandemic recovery.

“The counter-argument is that there's a size where these things become too big,” the source said. “And there's also an issue for me about where the real accountability [for the trust’s performance] then lies.”

They added that “there's a risk that as you start to expand your trusts into these mega-trusts that the unit of accountability for the quality of care becomes blurred, or less focused.”

'Fool's errand'

Commenting on the MFT merger they said: “If the hypothesis is that everything will be better if you bring all the trusts together, is there any evidence that it has got better?”

“There are a lot of people I know who think that this journey towards larger trusts is a fool's errand,” they said.

The size of the trust itself, however, is just one of a number factors which is likely affecting its recovery.

Manchester’s population demographics, long-entrenched regional health issues and the significant impact from Covid on the region, are also partly to blame for knocking the trust off course, experts believe.

“One of the big problems Manchester faces is that the population that it serves is typically much more unhealthy than the rest of the country,” said Dr Luke Munford, a senior lecturer in health economics at the University of Manchester, said.

The area has some of the highest prevalence for certain disease conditions, while life expectancy is lower than the national average, he said.

According to research published in Lancet Public Health, life expectancy in Greater Manchester did slightly improve, compared with a control group, during the period of change at the Trust.

However, Hugh Alderwick, director of policy at the Health Foundation, said the findings only give a "limited picture" of the benefits of devolution on health.

He wrote in a blog: "Initial evidence from Greater Manchester provides hope that a mix of changes linked to devolution could contribute to better population health. But the study only gives a limited picture. It tells us that there was an improvement in life expectancy in Greater Manchester during devolution. But it doesn’t tell us why."

Greater Manchester also had some of the highest Covid-19 mortality rates across the whole country, while the North West saw one of the biggest drops to elective surgery.

Between 2019-2020 elective surgery in the North West reduced by 23 per cent, compared to the England average of 21 per cent, Dr Munford said.

Anecdotally, MFT was one of the worst affected from the shutdown of surgery in the region because it serves one of the most deprived communities, he added.

The area was also “almost consistently” in a tier three or four lockdown during the first year of the pandemic, whereas some parts of the country remained in tiers one and two.

Covid also had a longer-lasting effect on the trust. In January last year MFT had almost as many Covid inpatients as at the pandemic peak.

'The worst possible time'

“All of these factors aren't unique to Manchester, but when they multiply and the bundle becomes bigger and bigger, you can sort of understand it,” Dr Munford said, but agreed there would be some institutional factors at play.

Some of these health issues have been long entrenched, but devolution had begun to make a positive difference on the population's health, he added.

“The disproportionate effect of Covid because of mortality, hospitalisation, lockdown, shielding, [and] other conditions, it was almost the perfect storm, it was the worst thing to happen at the worst possible time,” Dr Munford said.

He admitted the “sheer size” of the differences in MFTs waiting list compared to other trusts across the country was worrying, but said the backlog would not be cleared overnight.

But James Pearson, chairman of the Manchester Conservatives, said he believed devolution had been detrimental to healthcare in the area, as it removed some of the checks and balances on service providers and limited patient choice.

Previously, three hospitals in one area may have offered a service, such as physiotherapy, but now after merging them under MFT it means there’s “only one shop to shop at”, he said.

'The Trust is too big'

The Competitions and Markets Authority did warn the merger would substantially reduce competition among health services in the region, but agreed to the plans as the benefits to patients were expected to be “more significant”.

“The Trust is too big, it’s not providing the services that we need and it's putting patients at risk, and, overall, because there is no longer choice for patients within the trust area it means for those who really need it there is no alternative,” Mr Pearson said.

The trust said along with the impact from Covid and poor health inequalities in the area, its inability to rely on mutual aid from neighbouring trusts, due to the complexities of its patients, makes it harder to clear the backlog.

Manchester was affected by Covid to a greater extent than many other parts of the country and the Trust took many patients from other hospitals during the pandemic.

A spokesperson for Manchester University NHS Foundation Trust said: “Staff across our 10 hospitals and two community services are working incredibly hard to improve access times for our patients, who have some of the greatest health challenges in the country.

“We’ve faced significant challenges with COVID and the complexity of the care which we provide to patients. We are already seeing some progress, including a reduction in our waiting list for patients with suspected cancer by 48 per cent from its peak in September 2022 to March this year.”

Manchester was affected by Covid to a greater extent than many other parts of the country and the Trust took many patients from other hospitals during the pandemic