Agenda item

Central & North West London NHS Foundation Trust (CNWL)

Ms Kim Cox, Hillingdon Borough Director at CNWL, advised that the Trust's Quality Priorities for 2016/2017 had been: patient and carer involvement; and staff engagement.  CNWL wanted patients and their carers to be actively involved in their care or treatment so that they felt informed and felt that their care or treatment helped them to achieve the health outcomes which mattered to them.  To achieve this:

·         the Trust Board had made a public commitment to the #hellomynameis... campaign in September 2016 and 89% of teams had volunteered to sign up.  It was noted that, whilst more staff had adopted the approach, this had not yet been formalised.  It was suggested that, as this was a best practice approach, it should not be voluntary and all staff should be required to participate.  Ms Cox would take this suggestion back to the Board;

·         Carers Week celebrations had been organised by the Carers Council with 200-300 people taking part;

·         a Trust wide Patient Reference Group had been set up to bring together patient representatives, Governors and Healthwatch members.  In addition, the Hillingdon Service User Group, which was chaired by a local service user, had been developing a newsletter regarding the performance of services;

·         patients and carers were being trained to participate in the Trust's recruitment and selection process.  Interviewers were provided with interview training and met with the chair of the interview panel to go through the job description and interview questions.  They were then involved in the decision making process and were invited to a subsequent feedback session; and

• Peers Support Workers had been introduced and were working on inpatient wards and with CPH services.

 

The response rate for the Friends and Family Test (FFT) across the Trust had increased by 150% on the previous year with satisfaction rates remaining above 90%.  However, the response rate in Hillingdon had not been high from mental health (MH) and CAMHS service users.  Service users were regularly asked to complete questionnaires throughout their treatment and Ms Cox felt that this low response rate might be as a result of feedback fatigue.  To try to improve the response rate, service users had been involved in redesigning literature in an easy read format. 

 

A Community Physical Health (CPH) survey had been undertaken in the last year.  Hillingdon's results from this survey put it in the top 10% nationally.  However, it was recognised that CPH services did not face the same challenges as MH services.  Furthermore, Hillingdon received more complements and a lower complaints rate in relation to MH than any of the other authorities covered by CNWL. 

 

The CPH Service annual patient experience survey 2016 found that:

•         2,613 patients responded which was a 29% response rate (this was an increase on 2015);

•         93% of respondents stated that their overall experience of service was excellent, very good or good (94% in 2015);

•         87% of respondents were likely to recommend the service to friends and family (88% in 2015); and

•         95% of respondents felt able to get appointment at a suitable time(this was an increase on 2015).

 

CNWL wanted its workforce to feel engaged, motivated and valued, so they would give their best or go the extra mile for colleagues, patients and carers.  As CNWL had experienced challenges in recruiting to MH posts, staff were solicited for help, benefits packages were reviewed / promoted and leadership programmes had been developed to help career progression.  The staff survey had highlighted the following:

·         81% of MH staff reported in the staff survey that they would recommend the Trust as a place to receive care or treatment to a friend or relative (against 74% for the Trust as a whole);

·         81% of Hillingdon MH staff felt safe to raise concerns within the organisation about unsafe clinical practice;

·         82% recorded that CNWL acted on concerns raised by patients and carers; and

·         81% recorded that care of patients was the Trust's priority.

 

The National Staff Survey had highlighted six areas where CNWL was below average.  Ms Cox advised that these tended to be as a result of staff feeling that they needed to attend work even when they were feeling unwell or where they were working additional unpaid hours.  To help those staff that were feeling stressed at work, the Trust made occupational health referrals to support them.

 

The quarter 4 result for patients feeling definitely and to some extent involved in their care or treatment was 81% in MH.  It was recognised that this had slipped from the previous year's results and that further work was needed to improve this response.  However, it was also noted that there were some MH service users that were receiving treatment against their wishes and that this would be reflected in their responses.  97% of CPH patients felt involved in their care or treatment. 

 

With regard to staff turnover, Ms Cox advised that CPH had achieved 16% and MH was at 11.2% (this had improved significantly from 27% in 2015) against a target of 15% (the target had been revised after it was achieved in quarter 1).  Retention of staff had improved significantly over the last year but the Trust still struggled to recruit qualified nurses for inpatient wards (particularly in MH where there was a 28% vacancy rate for Band 5) and consultant psychiatrists.  CNWL had had a presence at recruitment fairs and had made some improvements in relation to bank staff which had reduced the need to use agency staff. 

 

There was a national shortage of MH staff which had been exacerbated by a reduction in the number of students training in this specialism and competition from central London hospitals.  An advertising campaign was being developed and a golden handshake had been introduced to encourage more applications.  Although recruitment had been undertaken nationally, consideration was now being given to recruiting internationally. 

 

A consultation event had been held involving patients, service users, carers, staff and stakeholders to help set the Quality Priorities for 2017/2018.  For 2017/2018, the two key levers to quality remained as:

·         Patient and carer involvement; and

·         Staff engagement. 

 

By continuing with these two Quality Priorities, CNWL believed that it would be able to build on the gains made during 2016/2017.  Furthermore, by adhering to NHS planning principles that spanned 3-5 years, the Trust would be able to align with national programmes such as the CQUIN and continue to embed the actions taken so far throughout the past year.  A local event would be held in the next couple of weeks for service users to help identify local targets.  Ms Cox advised that she would be happy to feedback to Members on the outcome of this event. 

 

Although Members recognised that there was a requirement for CNWL to publish one report for the whole area that it covered, they were disappointed about the lack of Hillingdon related information included in the draft.  It was noted that this had previously been raised and that the Quality Report had subsequently included area specific information for each of the boroughs covered.  It was felt that withdrawing this information from the report was a step backwards.  Ms Cox advised that consideration could be given to including appendices with local information and would relay these comments back to the Quality Governance Team.  The Committee gave its full support to changes that would result in a greater level of local information being included in the report. 

 

Concern was expressed that the information contained within the report rarely provided the reader with comparative past performance.  Members also noted that there were a significant number of targets where the Trust had overachieved.  The target for reducing staff turnover had been achieved by the end of quarter 1 and, as such, had been revised midyear.  The Committee questioned why this hadn't been done with other targets or, where the same target had been overachieved the previous year, why a more challenging target hadn't been set at the start of the year.  Whilst Members were aware that some targets would be set nationally, they could see no reason why an additional local target could not also be set.  Ms Cox advised that consideration could be given to alternative indicators for the next year.

 

Members were pleased to note that CNWL had scored the highest nationally in relation to the percentage of patients on the Care Programme Approach that were contacted within seven days of them leaving the hospital (97.3%).  However, Members expressed significant concern about the increase in the number of patient safety incidents since the previous reporting period and the total number of patient safety incidents that had resulted in severe harm or death.  Ms Cox would establish the nature of these incidents and forward this information on to the Democratic Services Manager for circulation to the Committee.  If possible, Members suggested that a benchmark be provided to give the figures some context.

 

It was recognised that a significant amount of investment had been undertaken into CAMHS and, as such, it was suggested that the readmission rates for patients aged 0-15 (1.4%) and those aged 16+ (4.5%) should be lower.  Ms Cox advised that there was an expectation that some patients would need to be readmitted as this was the nature of their condition.  In Hillingdon, the mental health patient readmission rate for the inpatient wards was currently at 3.2%. 

 

Concern was expressed that, although the Trust had achieved 5.6% against a target of <7½%, the average percentage of hospital beds that were being used by patients who should have been discharged had increased by 1.2% over the last two years.  Ms Cox advised that there had been an issue in Hillingdon over the last few months where placements were just not available for patients.  Examples of reasons for delayed transfer of care (DTOC) included where a patient had no recourse to public funds, had to wait for a specialist placement or were waiting for housing.  Approximately 18% of patients in Hillingdon were currently experiencing DTOC.  To address this, Council officers were now attending weekly meetings with CNWL.  However, there were still issues where patients in Hillingdon were not resident in the Borough and another CCG needed to take responsibility for the individual.  Although Ms Cox believed that the Council was working well with the Trust, she suggested that more could be done in relation to fast tracking emergency housing. 

 

The report highlighted that 23% of staff had experienced harassment, bullying or abuse from staff in the last 12 months.  This had increased by 2% over the last two years.  Ms Cox advised that the result for this indicator in Hillingdon was approximately 6% and that there were 2-3 formal grievances lodged in the Borough each year.  There had been an increase in the levels of stress and pressure that staff felt so that, when their manager asked them to take on additional tasks, this could sometimes be misinterpreted.  Mr Graham Hawkes, Chief Executive Officer at Healthwatch Hillingdon (HH), noted that this correlated to the increase in complaints received by HH in relation to staff attitude. 

 

Ms Cox acknowledged that there were areas for improvement.  To this end she would be visiting other sites within the Trust where best practice existed so that this excellence could be transferred and applied in Hillingdon.

 

The Hillingdon Hospitals NHS Foundation Trust (THH)

Ms Jacqueline Walker, Interim Director of Patient Experience and Nursing, and Mr Imran Devji, Director of Operational Performance, attended the meeting.  Ms Walker advised that a stakeholder event had been held in November 2016 to solicit feedback on the Trust's performance over the last year and to identify areas of focus for the forthcoming year.  This information had then been triangulated with information held in relation to complaints, PALS, staff feedback, etc.

 

Over the last year, THH had exceeded its target for patients being assessed for risks of developing hospital acquired thrombosis and, with regard to cancer, performance was being well maintained for all of the national waiting times standards to the extent that the Trust was above the national average.  Other key quality achievements in 2016/2017 included:

·         a reduction in emergency readmissions within 28 days;

·         maintaining a high referral to treatment (18 weeks) performance which was better than the London and national average;

·         improved patient satisfaction as measured by the Friends and Family Test (FFT) which was better than the London and national average;

·         an improved patient safety incident reporting rate; and

·         Clostridium Difficile (C.diff) infection rates had remained below the national average.  A detailed root cause analysis had been undertaken of the incidents which resulted in two of the cases being identified as a lapse in care. 

·         Members were advised that unannounced mock inspections were undertaken by THH in its clinical areas to ensure that the Trust was adhering to the CQC standards.  Following these inspections, feedback was provided to the relevant department staff and reported to the Divisional Management Teams.  Infection control and other indicators would continue to be tracked.

 

Members were advised that care home interventions had resulted in a reduction in admissions.  To ensure this trajectory continued, GPs and Social Care had been working closely with THH.  Furthermore, CNWL had advised that it would be putting mental health nurses into Hillingdon Hospital to support dementia patients where DTOC issues had been identified.  As the number of people with dementia was increasing, it would be important to maintain a focus on this vulnerable group. 

 

With regard to staffing, it was noted that recruiting to medical and allied health professional vacancies continued to be a challenge.  The Trust had undertaken international recruitment for nursing but was still waiting for many of those staff to start. However there had been some successes in some clinical areas, e.g., all nursing posts within A&E and paediatric A&E had been fully recruited to.

 

50 staff safety champions were being recruited as part of the Trust's Sign up to Safety campaign and they would work with the patient champions that were also being recruited to support the Trust’s safety improvement work.

 

At 3.85 out of 5, THH 's staff engagement score in the National Staff Survey was above the national average (3.81).  Overall, the Trust had scored above average in 17 areas, with 12 of these placing it in the top 20% of all acute trusts in England.  In the survey, 63% of staff stated that they would recommend the Trust as a place to work, which was above the average for acute trusts.  Ms Walker advised that she was unsure how the 3.85 figure engagement score was calculated but advised that it looked at areas such as whether staff felt that they were aware of what was happening in the organisation and whether managers were communicating and engaging effectively with staff (the introduction of initiatives such as the Freedom to Speak Up Guardian and the Cares Ambassador role would also have helped to improve this target).

 

In terms of CQUIN targets for 2016/2017, THH had achieved 100% of the following requirements:

·         Developing IT systems to support integrated care;

·         Evaluating current demand for hospital outpatient services and the implications on capacity requirements;

·         Providing specialist support, advice and guidance to GPs that would enable more patients to be cared for out of hospital where appropriate;

·         Providing evidence of best practice in the safe and effective handover of patients including at weekends;

·         Implementing an electronic handover system; and

·         Improving services for patients approaching the end of their life and supporting them to spend their last days in their preferred environment

 

However, the Trust had only partial achievement in:

·         Improving the health and wellbeing of NHS staff, visitors and patients (87%);

·         Improving identification and treatment of patients with suspected sepsis (88%) - this issue had recently been publicised in the national media so awareness was improving; and

·         Reducing the unnecessary use of antibiotics (60%).

 

There had been a significant amount of money invested, with more than £4m spent on improving and expanding children's services with a major refurbishment of children's A&E and a new four bed extension wing being built on Peter Pan Ward.  Services and facilities had been refurbished and upgraded such as building a new extended Clinical Decision Unit, new A&E triage rooms and staff offices.  A new outpatient pharmacy was being developed at Hillingdon Hospital and more than £300k was being spent on 400 state of the art cots, cribs and electric beds as part of a hospital-wide replacement programme across both sites which would help staff with manual handling.  It was anticipated that these works would create a better environment for staff as well as patients. 

 

Areas of performance that had not met the agreed targets in 2016/2017 included:

·         Patient Reported Outcome Measures (PROMs) for hip replacement - because Trust performance was below the national average and had reduced since 2015/2016, targeted work was being undertaken in relation to patient expectations about expected mobility post operation;

·         Written complaints - 67.7% of complaints had been responded to within the specified time against a target of 90%.  It was noted that there had been some long term sickness within the complaints team which affected their performance but also senior nurses had been busy dealing with capacity and operational issues to support and improve A&E and patient flow which took their time and attention away from ensuring that complaints were on track.  This had all impacted on achieving this target;

·         MRSA bacteraemia - there had been one case identified within the year.  The Trust had learnt from this case and new clinical guidelines had been introduced as a result;

·         FFT response rates - A&E had achieved 8.7% against a target of 20% and Inpatients had achieved 27.3% against a target of 30% (the 30% target had been achieved in March 2017).  As national A&E response rates were approximately 14%, THH had introduced electronic solutions as well as using volunteers to help improve this response rate and was considering a text service intervention.  Given that A&E had faced significant capacity challenges through the year, the Committee noted that THH had performed better than could have been expected;

·         Staff turnover - the turnover rate at THH had been 16% in 2016/2017 against a target of 13%.  Members were advised that recruitment had been undertaken in the Philippines with 11 new staff starting in August 2017 (there had been some issues with regard to some of the other 85 candidates in terms of passing the English language test).  To help fill the 106 vacancies and make the Trust more attractive, flexible working arrangements and the opportunity to work towards NMC registration were being promoted.  THH continued to recruit students from, and run recruitment events at, Buckinghamshire New University and it was anticipated that the withdrawal of bursaries would reduce the number of students wanting to train as nurses which would make recruitment even more challenging; and

·         Four hour A&E access target - although the year end position was 83.9%, during March 2017 it had been 86.8% and in the week commencing 20 March 2017 it had been 93.2%.  A lot of work had been undertaken to identify the blockages and improve partnership working.  In addition, blue light activity had increased by 19.5% during 2016/2017 and average Type 1 attendances had increased from 145 in 2014/2015 to 189 in the winter of 2016/2017, with attendances exceeding 220 on three occasions in January 2017.  It was suggested that the increase in blue light activity was as a result of an increase in, for example, patients' acuity, respiratory issues and paediatric patients.  There had been improvements in the ambulance handover time with performance shared through the A&E Operational Group and the London Ambulance Service (LAS).  These improvements had been attributed to ambulance streaming being in place within a dedicated handover area.  Although blue light admissions had now reduced, there had been an increase in other conveyances.  

 

Following the CQC inspection in 2014 where THH was rated as 'requires improvement', the Trust had been working through a detailed improvement plan.  As a result: compliance rates for staff training for all statutory and mandatory training continued to exceed the target; the National Specification for Cleaning targets had been exceeded during 2016/2017; compliance had improved in relation to hand hygiene and 'bare below the elbow' practice; and there had been significant improvements on medicines management in clinical areas.  However, the Trust still faced challenges with regard to adequate storage facilities for clinical and pharmaceutical supplies. 

 

Although THH had not achieved the 90% target for National Early Warning System (NEWS) compliance to support early escalation of the deteriorating patient, there had been some improvements in performance in 2016/2017.  Ms Walker advised that there had been instances where non compliance was as a result of the documents not being completed properly rather than the patient not being assessed.  To this end, the revised policy was being re-launched.

 

With regard to the Trust's 2016/2017 priority to achieve improvement in relation to seven day working, Members were advised that an audit had been undertaken.  Results of the audit were awaited and it was hoped that these would be included in the final version of the Quality Account report. 

 

THH had aimed for a 5% reduction in complaints related to key themes that included communication and staff attitude.  There had been a reduction in complaints related to these themes as well as a reduction in overall complaints.  This information still needed to be triangulated. 

 

Looking ahead, the Trust's priorities for 2017/2018 had been aligned with the Sustainability and Transformation Plan (STP), the Borough Strategy and the Trust Strategy.  The priorities for 2017/2018 would be:

1.    Improvements to end of life care;

2.    Continuing to deliver the seven day working priorities;

3.    Improving the care of patients with dementia; and

4.    Improving the discharge process.

 

The Committee advised that, if possible, it would be useful to have the quality report as far in advance of the External Services Scrutiny Committee meeting as possible to ensure that Members had time to read and digest the information contained therein. 

 

Healthwatch Hillingdon (HH)

Mr Graham Hawkes, Chief Executive Officer at HH, thanked THH for its cooperation and the access that had been given to liaise with patients on the wards.  The discussions that HH representatives had had with patients had highlighted the value of face to face feedback as opposed to questionnaires. 

 

HH had undertaken two reviews over the last year:

• Expecting the Perfect Start - this review had looked at how the closure of maternity services at Ealing Hospital had impacted on Hillingdon and Ealing residents.  On the whole, patients reported having had a positive experience and a high satisfaction rate.  However, there were areas identified for improvement, approximately 80% of which had been identified in the THH improvement plan (issues such as the comfort of the waiting room still needed to be addressed).  The research had shown that Ealing residents had a more adverse experience which was not unexpected as the journey from Ealing had been known to take up to three hours when the roads were seriously congested.  Furthermore, Hillingdon did not have the capacity for all of the women that wanted to give birth there and priority was given to Hillingdon residents.  Also, Mr Hawkes noted that GPs were not always advising women that they had a choice about where they gave birth.  Members were advised that a Government report in 2016 had found that a large number of women did not know who their named midwife was.  Clearly, improvements needed to be made and North West London had become an early adopter for new processes to improve continuity of care; and
• Safely "home" to the right care - this review had looked at hospital discharges and had resulted in a lot of improvement work being undertaken at the hospital and in the community.  Mr Hawkes had not agreed with all of the information about communication included in the THH Quality Account and advised that communications at the hospital were being developed.  Although caring, staff at THH were under a lot of pressure and this sometimes affected their adherence to procedures (rather than their attitudes).  Mr Hawkes advised that some improvements had already been made (discharge lounge) and others were in progress (for example, HH would monitor the roll out of a redesigned booklet which had been developed by the hospital in conjunction with its partners). 

 

Members congratulated HH on the production of the two pieces of work.  It was noted that Mr Hawkes' presentation had highlighted the strong partnership working in Hillingdon and recognised the great work that was undertaken by the NHS under pressure.

 

RESOLVED:  That:

1.     Ms Cox would speak to the Trust Board about the possibility of sign up to the #hellomynameis... campaign becoming compulsory for all staff;

2.     Ms Cox provide an update at a future meeting on a local event being held for service users to help identify local targets;

3.     Ms Cox establish whether local information could be included again in future Quality Account reports;

4.     Ms Cox establish whether alternative indicators could be set for the next year in additional to national targets;

5.     Ms Cox establish the nature of the patient safety incidents and forward this information (and a benchmark) to the Democratic Services Manager for circulation to the Committee; and

6.     the presentations be noted.