Agenda item

The Chairman welcomed those present to the meeting and congratulated Dr Steve Hajioff on his recent media exposure and his role in the development of NICE guidelines to reduce the number of people who died as a result of late cancer diagnoses. 

 

Central and North West London NHS Foundation Trust (CNWL)

Dr Pramod Prabhakaran, Divisional Medical Director for Hillingdon, stated that the CQC had undertaken an inspection of CNWL in February 2015.  The resultant report, which had been included on the agenda, had been discussed at a summit meeting with the CQC on 18 June 2015.  This report covered the community and mental health service provision so effectively comprised 14 reports which then determined the overall CQC rating (1 'inadequate', 10 'good', 1 'outstanding' and 2 'requires improvement').  In addition, CNWL had compiled a summary report for each of the boroughs for which it provided services - this had been circulated to Members in hard and soft copy prior to the meeting.  Ms Kim Cox, Borough Director, would forward an updated version of this report to Democratic Services for circulation to the Committee. 

 

Members were advised that the inadequate rating included in the CQC report had been in relation to acute wards for adults of working age and Psychiatric Intensive Care Units.  It was noted that the general bed occupancy had been 120% but that the staffing levels had not reflected this increased activity.  Furthermore, there had been instances where patients had been moved temporarily to older adults units.  Dr Prabhakaran advised that action had since been taken to address this issue (for example, beds were now monitored by staff at least twice each day and bed occupancy in Hillingdon had reduced to 100% as a result of active monitoring and a clear escalation process). 

 

It was noted that the bed pressures experienced by CNWL had been in relation to the general adult population.  However, as there had been some excess bed capacity on the dementia ward, these beds had been used to alleviate pressure elsewhere, for example, in April and May 2015 there had been 125 occupied bed days in Hillingdon due to foreign nationals coming into the Borough via Heathrow airport.  Ms Cox advised that it was important to proactively manage the bed spaces whilst ensuring that alternatives were available by strengthening the community mental health team offering and working closely with the local authority. 

 

With regard to the 'requires improvement' rating for community based mental health services for adults of working age, it was noted that the CQC had looked at the capacity for community care coordination.  Although there had been no waiting list by the time the CQC inspection had been undertaken, this had not always been the case.  In addition, the ward for older people with mental health problems had been rated as 'requires improvement' due to the layout of the single sex accommodation in relation to the location of facilities and the condition of the walls, carpets, etc.  These environmental issues were being addressed (for example, the configuration of the ward was being altered) and were expected to be resolved by the end of the week. 

 

Other issues raised in the CQC report included:

·         Nurses attending to patients before removing their own coats - staff had been reminded of the need to remove their coats before starting work;

·         Inappropriate bags being used to carry equipment - new bags had since been purchased and distributed to staff;

·         Care coordinators not being identified - duty team leaders had since been allocated a small caseload to ensure that care coordinators were identified for all cases; and

·         Resourcing and waiting time issues in relation to CAMHS - CNWL had been working closely with Hillingdon Clinical Commissioning Group (HCCG) to implement a waiting list initiative which could be extended into 2016/2017, subject to funding being provided by HCCG.  Whilst Members were pleased that this issue was being addressed, concern was expressed about the long term sustainability of these measures if funding was only available until 2016/2017.  It was noted that longer term measures would be planned at a North West London level.

 

Members were advised that 30 actions had already been undertaken following the publication of the CQC report to address the issues highlighted therein.  Only a few actions were still outstanding.  Dr Prabhakaran stated that the Trust had an ongoing quality assurance process in place and, as such, CNWL had already been aware of some of the issues identified by the CQC and had started to put measures in place to address these. 

 

Concern was expressed that, if the issues for action had already been identified by the Trust prior to the CQC inspection, why had these not previously been resolved.  Ms Cox advised that, whilst these issues had been identified, some issues had not been easy to resolve.  It was suggested that the Committee look at the possibility of holding a special meeting to discuss this matter further. 

 

With regard to resourcing, it was noted that there was both a staffing and a funding shortage at CNWL.  Ms Cox stated that, although funding in Hillingdon was not as good as for Westminster, Kensington and Chelsea or Brent, it was on a par with Harrow (although approximately £4m less).  The majority of funding received by CNWL for Hillingdon was from HCCG. 

 

Dr Steve Hajioff, the Council's Director of Public Health, advised that, whilst Harrow was a geographical neighbour, it was not a statistical neighbour and therefore not comparable with Hillingdon.  That said, he acknowledged that HCCG's contribution to CNWL was marginally less than its statistical neighbours which was reflective of its historic allocation for mental health. 

 

Dr Reva Gudi, Vice Chairman of HCCG, noted that, approximately 8 months ago, it had been acknowledged that Hillingdon was historically underfunded and that funding had subsequently increased, although it was still approximately 7% adrift from its neighbours.  She recognised that funding was less when compared to some of the Borough's neighbours for mental health, but advised that she had not seen the actual report that CNWL referred to, so could not comment on the actual figures and gap.  She was happy to return to a future meeting to update the Committee once the report had been received and to provide Members with further information about any impact that the underfunding might have had on patient outcomes.  It was agreed that this be considered at the Committee's next meeting on 17 September 2015. 

 

Dr Gudi noted that, with regard to CAMHS, there appeared to be more complex Tier 3 cases in Hillingdon presenting to services.  As a result, there was a need for HCCG, CNWL and the Council to work closely to address this demand through the adoption of preventative and early intervention measures.  Consideration would also need to be given to the way that services were commissioned and prioritised to identify the greatest current need as well as the greatest future need.  Dr Prabhakaran added that it was a matter of prioritising based on limited resources.  

 

Ms Cox advised that CNWL had no waiting list for hospital mental health beds in Hillingdon, despite having the highest number of referrals into secondary mental health services from GPs, etc, of the five London boroughs covered.  In addition, Hillingdon had the shortest waiting times of these London boroughs.  Ms Cox noted that she would be happy to return to a future meeting to update Members on the service redesign that was being undertaken in relation to community mental health services for adults. 

 

Dr Steve Hajioff advised that a recent Public Health detailed assessment report had identified that the number of people with mental health issues would grow faster than the overall population in Hillingdon.  It was anticipated that the demand would be particularly pronounced in relation to CAMHS, acute mental illness and dementia.  As such, these issues would require ongoing investment. 

 

Concern was expressed that the CQC inspection had highlighted variations in standards, practice and environments between services which meant that some patients did not always receive services of an acceptable standard.  Dr Prabhakaran advised that, although there was a programme in each service which looked at any new guidance that emerged, he would not agree that there was a huge variation between services.  He noted that structures and systems were in place but that the organisation had expanded and was in the process of standardising these across the extended Trust.  Members queried whether this expansion had resulted in CNWL becoming too big and whether it should be broken up into to more manageable pieces.  Ms Cox advised that she would provide Democratic Services with a written update in relation to this issue for circulation to the Committee. 

 

Members were pleased to note that a standardised IT system was being implemented by CNWL but queried why, after 13 years, consideration was only just being given to bringing this together. 

 

With regard to ligature points, Ms Cox noted that CNWL would never be 100% ligature free.  Despite risks being assessed, these had not necessarily been transferred into care plans.  As such, consideration was being given to how risk could be managed more appropriately.  Ms Cox would provide Members with a document in relation to this issue, specific to Hillingdon. 

 

Although Ms Cox believed that CNWL had performed well locally with regard to risk assessments through monthly audits that were linked to care plans, the organisation had identified issues in relation to discharge and handover prior to the CQC inspection.  It was noted that internal transfers had not been as smooth as the organisation would have liked and that this had resulted in a service redesign.  Daily meetings were now held and any issues of concern were quickly escalated to Ms Cox. 

 

Members were assured that, whilst they were tackling the 'musts' identified in the CQC report, CNWL was also looking to address the 'shoulds'.  It was noted that the CQC would re-inspect the Trust at a later date to ensure that action was being taken to address the issues highlighted in the report. 

 

London Ambulance Service NHS Trust (LAS)

Mr Chris Miles, LAS Ambulance Operations Manager, advised that Hillingdon had exceeded the London average in relation to response times to Category A 8 calls so far in the year to date.  Furthermore, Hillingdon CCG was the 7^th highest CCG in London for Cat A incidents between April and June 2015 and the 5^th busiest in 2014/2015. 

 

Members were advised that Hillingdon had been included in a clock change trial which also revised the Red 1 calls to include incidents such as pregnant women about to give birth.  Ms Pauline Cranmer, Assistant Director of Operations - North West Sector for the LAS, noted that all seriously unwell calls had not been affected and that the pilot had enabled an enhanced triage for a small cohort of lower acuity calls.  Ms Cranmer stated that the nature of each call varied and that there were hundreds of triage determinants.  The pilot had reduced the number of wasted journeys, therefore protecting the most life threatening calls, and had resulted in a 4.1% reduction in demand. 

 

Mr Miles stated that Hillingdon's performance had been good in relation to identifying the most appropriate care pathway for callers which resulted in 21% of calls not being conveyed (against the London average of 15.1%).  It was noted that this reduction would have reduced the pressure on primary care. 

 

In terms of performance, Members were advised that service demand was now being managed more effectively by the Clinical Hub, where the priority of calls was adjusted as the call progressed.  This had also resulted in a reduction in the multi attendance ratio to make best use of the available resources.  Furthermore, as the Metropolitan Police Service (MPS) was one of the LAS's biggest service users, the LAS would now call the MPS back to glean further information about the requirements of the call and the response time needed. 

 

With regard to recruitment, Mr Miles advised that the LAS was aiming to recruit 800 new staff during 2015/2016, some from Australia and New Zealand.  Members were advised that these recruits would need to be registered with the Healthcare Professionals Council before they could transfer and then undertake a period of training to bring them up to the London standard (as there were differences in some treatments between the two continents).

 

Concern was expressed in relation to recent reports of staff leaving the LAS as a result of bullying and harassment.  Ms Cranmer stated that there were many more opportunities now available to paramedics in alternative healthcare settings such as GP surgeries, UCCs, etc.  This, coupled with the higher cost of living in London, had resulted in a large number of staff leaving the LAS. 

 

Members were aware that the CQC had undertaken an inspection of the LAS during June 2015.  It was anticipated that the CQC's report would be available in September/October 2015. 

 

Insofar as complaints were concerned, it was noted that the 63 complaints received in Hillingdon during 2014/2015 accounted for 4.5% of the total number received by the LAS.  Of these, the majority (45) had been in relation to delays, with 11 in relation to conduct, 4 about conveyance and 1 each with regard to road handling, clinical treatment and safeguarding.  It was recognised that it was important to manage people's expectations as sometimes people's perception of what would happen was not necessarily what actually took place (for example, the patient may be told that they should call their GP the following day). 

 

The Hillingdon Hospitals NHS Foundation Trust (THH)

Ms Bev Hall, Deputy Director of Patient Experience and Nursing at THH, advised that a number of actions had been taken to ensure that patients were able to express their worries and concerns.  For example, posters were displayed on each ward to identify key members of staff, a booklet had been produced and given to all patients on admission ("Working Together") setting out the escalation process and new bedside information boards had been introduced with key information about each patient (linked to the recommendations in the Francis Report). 

 

Ms Hall explained the Trust's complaints process and advised that consent would need to be sought from the patient if a complaint was made by a friend or relative involving them.  All complaints were investigated, even if they were not raised by the patient themselves.  It was noted that complaints could be made in writing, by email or over the telephone and were dealt with by the Complaints Team which comprised three members of staff.  The Manager of this team had made significant improvements since starting in 2014, with a reduction in the number of complaints reopened from 32 in 2013/2014 to 9 in 2014/2015. 

 

With regard to response timescales, simple complaints could be investigated and a response provided to the complainant within 30 days.  However, a target of 60 days had been set for more complex complaints that might involve a number of different agencies.  Although responsiveness was important, it was thought equally important to ensure these deadlines were not achieved simply by forgoing a thorough investigation. 

 

Members were advised that there were a number of key subjects raised in the complaints received by THH and that more than one of these issues may be present in a single complaint:

·         Clinical care medical staff;

·         Communication / information to patients;

·         Clinical care nursing staff;

·         Appointments (OPD & A&E);

·         Attitude (nursing staff);

·         Attitude (medical staff); and

·         Discharge.

 

It was noted that a number of improvements had arisen from complaints which included:

·         the availability of 50 new coin operated wheelchairs for public use at the hospital;

·         the provision of Parkinson's Disease training for multi-disciplinary staff (this training would be repeated in 2015/2016) and the introduction of a Parkinson's Disease visual alert magnet for use in conjunction with the bedside information boards;

·         the introduction of a transfer checklist;

·         training diabeticare staff to remove plaster casts - Ms Hall would forward information in relation to the number of patients using the diabetes / podiatry service and whether the service tended to be for the more serious cases; and

·         the introduction of a new subject code for end of life care and associated sub-subject codes. 

 

Members were advised that, about eight weeks after a complainant had been contacted with the results of THH's investigation, they were sent a user satisfaction survey.  Although the majority of responses to this survey indicated that the complainants were happy with the timeframe and helpfulness of staff when raising their complaints, there was still work to be done in relation to building confidence that raising concerns would not lead to discrimination.  Whilst it was recognised that raising confidence would be difficult, key generic information and broad expectations had been included in the Working Together booklet to ensure that patients were well informed. 

 

It was suggested that, rather than reinventing the wheel, solutions to issues that had arisen through complaints be shared with other Trusts.  Although each complaint was unique, it was recognised that there may be solutions identified which could be implemented by other Trusts.  Ms Hall would establish whether this kind of information sharing was something that was undertaken by THH and forward this to the Committee. 

 

Royal Brompton and Harefield NHS Foundation Trust (RB&H)

Mr Nick Hunt, Director of Service Development at RB&H, advised that, in 2014/2015, the Trust's hospital acute inpatient services had received 54 written complaints, 47 of which had been upheld.  Of the 26 complaints received during the same period in relation to hospital acute outpatient services, 21 had been upheld. 

 

It was noted that a large number of the complaints received by the Trust originated from family members of patients.  This in itself sometimes proved complicated when the different family members themselves did not necessarily agree with the submission of the complaint. 

 

Additional information in relation to the complaints received by RB&H during quarter 4 of 2014/2015 was circulated to Members.  It was acknowledged that complaints about transportation had not been included within the information provided to the Committee as it added very little to the overall picture (generally these complaints were in relation to public transport at Harefield Hospital and car parking at Royal Brompton Hospital).  Mr Hunt highlighted a number of issues that had arisen from complaints as set out in the information circulated.  The document also gave the result of the investigation and the leaning outcome in each instance. 

 

With regard to the development of the Harefield Hospital site, Members were advised that the planning application for Phase I had been granted.  Consideration was now being given to the development of a traffic management plan to mitigate the impact of additional vehicles and reduce the usage of cars by patients and staff - it was anticipated that this project would be completed in the next financial year.  Although the planning application for Phase II had been granted, consideration would now need to be given to the associated finances.  With regard to Phase III, effort would be made to undertake private fund raising to support this project. 

 

Concern was expressed that, with regard to patient transfer, patient records were not held centrally at a national level to ensure that they were accessible to all health professionals.  It was noted that the NHS had spent a significant amount of money to try to achieve a national patient record system but that this project had been unsuccessful. 

 

Hillingdon Clinical Commissioning Group (HCCG)

Dr Reva Gudi noted that the maternity services at Ealing Hospital had closed on 1 July 2015 and, it was anticipated, would result in an increase of approximately 800 births per year at Hillingdon Hospital.  In preparation for this transfer, various assurance processes had been undertaken and THH appeared to be well prepared for the additional births.  Staff would be transferred under TUPE from Ealing Hospital, active recruitment was underway and the maternity unit had been refurbished at Hillingdon.  It was noted that the midwifery offering at Children's Centres in Ealing would continue. 

 

Ms Hall would ask the Head of Midwifery at THH to provide the Democratic Services Manager with further detail about the challenges that this development had posed so that it could be circulated to the Members. 

 

Dr Gudi stated that HCCG now had joint commissioning responsibilities with NHS England and that the organisation had also participated in two North West London Commissioning In Common meetings (Healthwatch had also attended these meetings).  In addition, HCCG had held two local meetings and would be developing heat maps of pressure on GPs in the Borough. 

 

Concern was expressed that, despite public engagement being incredibly important, many meetings held by HCCG were not open to the public.  Dr Gudi stated that many HCCG meetings had lay member and Healthwatch representation.  She concurred that it was important that the public understood how and why HCCG made decisions to maintain transparency and would take these comments back to the Board. 

 

Hillingdon Local Medical Committee (LMC)

Dr Eleanor Scott, Secretary of the Hillingdon LMC and Medical Director of the Londonwide LMC, advised that there had been a number of challenges in the Borough.  She noted that there was a GP recruitment crisis where young doctors were not choosing general practice as a career (as it was no longer seen as secure) and older doctors were looking to retire.  It was estimated that there was a 25% shortage of GPs in training which was compounded by the number GPs that trained in London and then moved elsewhere. 

 

Given the national move towards transferring patients from hospital to home under the care of their GP, GP lists were increasing along with the number of appointments needed by each patient.  In 1995/1996, a GP would have an average of 4 consultations with a patient each year; in 2008/09 this went up to 5.5; in 2012/2013 this was 6.1; and it currently stood at 7 consultations per year.  Furthermore, the complexity of issues had increased which had resulted in consultations needing to last longer than they had previously (for example, cancer could be identified over a period, with several consultations being undertaken by the same GP).

 

Dr Scott noted that GPs were not paid by results and that there had been a reduction in practice income over the last year despite the increasing workload.  In addition, practices were often physically unable to expand their premises to accommodate the additional out of hospital work and, where premises were unable to adapt to enable disabled access, they were being shut down by the CQC. 

 

Members were advised that the Government was looking to remove £90m from Personal Medical Services (PMS) over those services provided by General Medical Services (GMS) contracts.  It was noted that this would seriously financially disadvantage PMS practices which was likely to result in closure or a reduction in numbers.  Dr Scott suggested that the resultant reduction in income and the loss of patient services would be so great that there would be benefit in Healthwatch Hillingdon requesting a clearer picture from NHS England.  The Committee agreed that consideration would be given to undertaking a review of the issues raised by Dr Scott.

 

Dr Scott noted that, with regard to the changes to the maternity services in Hillingdon, Ealing CCG had suggested that GPs take on at least three more antenatal appointments per patient to alleviate the pressure.  Whilst GPs would accept taking this additional work on, as antenatal care had come under the auspices of midwives for so long, GPs had become deskilled and would require additional training. 

 

Members were advised that patients with serious and enduring mental health illness and common complex mental illnesses were now being followed up by GPs.  There were huge risks associated with this move (GPs were not trained to take on this patient group and their workloads were already at capacity) which had been reflected in an increase in the insurances that GPs paid. 

 

Dr Scott advised that GPs across Hillingdon were in the process of forming federations of groups of practices (either CICs or companies limited by guarantee).  Whilst it was still early days, it was anticipated that the federations would be able to take contracts from the hospital for out of hospital care and would have the skills available to deal with this.  However, she noted that there was still a degree of upskilling required. 

 

RESOLVED:  That:

1.    Ms Kim Cox forward an updated version of the Hillingdon CQC summary report to Democratic Services for circulation to the Committee;

2.    the Committee look at the possibility of holding a special meeting to discuss the outcome of the CNWL's CQC inspection; 

3.    the issue of HCCG underfunding and the impact on CNWL be considered at the Committee's next meeting on 17 September 2015; 

4.    Ms Cox attend a future meeting to update Members on the CNWL service redesign that was being undertaken in relation to community mental health services for adults; 

5.    Ms Cox provide Members with further information in relation to ligature points and risk management, specific to Hillingdon. 

6.    Ms Hall forward information in relation to the number of patients using the diabetes / podiatry service;

7.    Ms Hall establish whether information sharing in relation to complaints solutions was something that was undertaken by THH and forward this to the Committee. 

8.    Ms Hall ask the Head of Midwifery at THH to provide the Democratic Services Manager with further detail about the challenges that the closure of Ealing maternity services had posed so that it could be circulated to the Members; 

9.    the Committee consider undertaking a review of GP funding and the associated pressures; and

10.the presentations be noted.