Agenda item

The Chairman welcomed those present to the meeting and thanked them for attending.  He noted that this year the Committee had scheduled two meetings on successive evenings with different Trusts invited to attend each meeting to discuss their Quality Account 2016/2017 reports.  Following the meeting, Democratic Services would contact attendees to get their feedback on this new format.

 

Royal Brompton and Harefield NHS Foundation Trust (RBH)

Mr Richard Connett, Director of Performance and Trust Secretary at RBH, advised that the Trust's month 12 position had been reported to the Trust Board on Wednesday 26 April 2017.  It was anticipated that the Trust's Quality Account 2016/2017 report would be circulated for comment on Friday 28 April 2017 to meet the 30 day consultation requirement

 

In 2016/2017, there had been 13 reports of Clostridium difficile with no lapses of care.  Although there had been one case of MRSA reported, investigations concluded that the patient had already been infected when they had travelled to the UK from Australia.  [NB: subsequent to the meeting, one case of Clostridium had been notified as a lapse of care.]

 

At the time of the meeting, the Trust had achieved 92.67% against the 18 week referral to treatment target with a month 12 trajectory of 92.58%.  Mr Connett also reported that there had been 4 outbreaks of infection, 11 serious incidents (down from 24 in 2015/2016) and 0 never events during 2016/2017.  Members queried whether the 50% reduction in the number of serious incidents and no never events reported for 2016/2017 was as a result of underreporting.  Mr Hunt assured the Committee that there had been higher levels of Datix reporting during the period and that this included near misses. 

 

NHS Improvement (NHSI) had introduced the Single Oversight Framework (SOF) on 1 October 2016 to replace the Monitor 'Risk Assessment Framework' and the NHS Trust Development Authority 'Accountability Framework'.  SOF had been designed to help NHS providers to attain and maintain Care Quality Commission (CQC) ratings of ‘Good’ or ‘Outstanding’ and was not a performance assessment in its own right.  Each Trust had been segmented into one of four categories with RBH being placed in segment 2 (segment 1: Providers with maximum autonomy; segment 2: Providers offered targeted support; segment 3: Providers receiving mandated support for significant concerns; segment 4: Providers in special measures). 

 

Mr Nick Hunt, Director Service Development at RBH, advised that the Trust had been inspected by the CQC in June 2016 and had been disappointed that it hadn't received more Outstanding ratings and that it had received an overall rating of Requires improvement.  However, Surgery had scored two Outstandings at Harefield Hospital which was predominantly in relation to the transplant service.  The Trust had attended monthly clinical quality review meetings where it had been stated that this was the best Requires improvements report that had been seen.  Work had since been undertaken in relation to the World Health Organisation (WHO) checklist and to increase the size of notices next to hand hygiene stations.  It was anticipated that the Trust would be re-inspected within the next month or two.  Members were advised that the Requires improvement ratings received by Royal Brompton Hospital in relation to Safe Surgery and Safe Critical Care were likely to be reflective of the state of flux that had occurred when eight consultants had left the Trust at roughly the same time to go and work at St Barts. 

 

With regard to the WHO regulations, there had been some concern about being bare below the elbow where medical staff were not always compliant.  Members were advised that the Trust was not always compliant with steps 1 and 5 of the process.  Despite WHO regulations being a one size fits all approach, the Trust was mindful that the regulations needed to be met. 

 

Members were advised that the CQC inspection had not highlighted any serious concerns that needed to be addressed.  Whilst the Trust was not satisfied with the result of the inspection, it was thrilled about the areas that had been deemed Good or Outstanding.  The Trust had made its criticisms of the inspection known to the CQC and had submitted a huge rebuttal of some of the comments that had initially been included in the report - these comments were later withdrawn.  Mr Hunt advised that, although the CQC split medical and surgical into different categories, this did not fit with the RBH approach where the two were merged. 

 

The National Early Warning Score (NEWS) report aimed to drive the step change required in the assessment and response to acute illness.  In an average district general hospital, there would be a low ratio of qualified nurses to healthcare assistants and qualified nurses to consultants.  At RBH, appropriate staff were already in place on each ward so there would be no need to escalate an issue - this was the nature of a specialist service.  Mr Hunt advised that the healthcare assistant/qualified nurse ratio had been skewed as the RBH would not hire or take agency staff if they were not familiar with the service. 

 

As all Trusts had now been inspected under the new regime, Mr Connett advised that, based on the CQC consultation document, from April 2017 the CQC was likely to move back to unannounced inspections.  It was anticipated that these would be more focussed inspections and would potentially mean that inspectors visited Trusts about which they had an expertise.  Royal National Orthopaedic Hospital had previously raised issues about the inspection of specialist hospitals. 

 

Mr Hunt noted that outpatient attendances at the Trust continued to be a challenge.  There were large numbers of outpatients, many of whom were long standing chronic care patients who would often disregard their appointments times and arrived on an ad hoc basis.  However, this was thought to be more of a congestion issue rather than an area of concern. 

 

Members were advised that there was a mandate for NHS England (NHSE) to prepare for a 28 day faster diagnostic target from 2018.  It was anticipated that this would help RBH to achieve the 62 day target.  Currently, the Trust struggled to meet the targets if a patient's diagnostic tests had not been completed when they were transferred or if the tests needed to be redone.  Although the patients that had exceeded the target had not come to any harm, they had potentially suffered more stress that they would otherwise.  For RBH, this was more of an issue with patients coming from Colchester, Buckinghamshire and Hertfordshire. 

 

London Ambulance Service (LAS)

Ms Briony Sloper, Deputy Director of Nursing and Quality at LAS, advised that 2016/2017 had been another challenging year as demand continued to grow and with an increased threat of terrorism.  A lot of work had been undertaken in relation to response models, demand management, hospital handovers and Sustainability and Transformation Plan (STP) engagement.  Furthermore, Advanced Paramedic Practitioners for urgent care were treating more patients in their own homes.  There had also been a focus on bullying and harassment and an improved representation of BME staff in the LAS workforce. 

 

Although there had been two re inspections since the CQC inspection in 2015 (September 2016 and February 2017), the LAS had remained in special measures.  Initial feedback from the most recent re inspection indicated that care continued to be good and that there had been significant improvements in medicines management and incident reporting.  However, further work was needed in relation to leadership development, governance and risk management.  It was anticipated that the CQC report setting out its findings from the most recent re inspection would be available towards the end of May 2017. 

 

With regard to the Staff Survey, Ms Sloper advised that the LAS had performed significantly better in 2016 in 67 of the 88 questions asked.  Performance for the remaining 21 questions had shown no significant statistical difference.  It was noted that the percentage of staff experiencing harassment, bullying or abuse from staff in the last twelve months had reduced from 38% in 2015/2016 to 32% in 2016/2017 (against a national average of 28%). 

 

With regard to the LAS 2016/2017 quality priorities:

·         a new Insight magazine had been introduced which staff had deemed to be educational.

·         further work was required in relation to STEMI and stroke patients.  Current performance deemed the LAS to be below the national average.

·         there had been some challenges around medicines management in relation to the logistics of managing medicines for 100s of vehicles across the Trust.  New mobile tablet technology had been introduced to facilitate paperless medicines management audits and real time upload of audit results.  There had been some inconsistencies with regard to the ratings received by ambulance trusts from different CQC inspectors in relation to medicines management and this was being collectively challenged. 

·         disposable blankets had been introduced.

·         when appropriate, mental health related calls were closed after a 'Hear and Treat' assessment by mental health nurses.  Control centre staff were learning from the approach taken by these mental health nurses. 

·         LAS staff had been working with London Fire Brigade to deal with bariatric patients when there were no bariatric vehicles available. 

 

For 2017/2018, the LAS quality priorities would be:

1.    Safety - it was thought that governance might still be an issue with regard to the CQC re inspection.

a.    Sign Up To Safety campaign.

b.    Improve outcomes for patients with critical conditions - there would be an impact on patients at the lower end of need in that they would be waiting longer as the focus would be on the sickest patients.

c.    Improve and embed learning from incidents.

2.    Caring

a.    Effective and consistent risk assessment completed for patients presenting with a mental health crisis - pathways were being redesigned.

b.    Ensure patients have timely and appropriate access to services - it was noted that the biggest user of the 999 service was GPs, followed by the police, then patients.  Work would need to be undertaken to manage demand from colleagues and it was suggested that the LAS work with the Council's Communications Team to educate residents about the impact that frequent callers had on the service.  If a call was received from someone saying that they were experiencing chest pains, they were deemed to be high risk and, even if it was the fortieth time that they had called that day, an ambulance would have to be dispatched to them.  There were 750 LAS staff in North West London and two specialist managers that dealt with frequent callers.  Frequent caller interventions had been put in place which had resulted in one patient costing an average of £57.86 and taking 6 hours of staff time (between March and July 2016 this had been £11,443 and 39 hours for each frequent caller).  Ms Caroline Morison, Chief Operating Officer at Hillingdon Clinical Commissioning Group (HCCG), advised that HCCG held fortnightly meetings with partners in Hillingdon about frequent callers and was able to talk to GPs about specific patients.  A dedicated telephone line had been introduced for GPs so that they could bypass the 999 line.  However, Ms Sloper advised that the LAS was often called to act as a taxi service/mode of transport to take non emergency patients to A&E.  As such, the LAS felt a responsibility to share data with GPs and, to help educate them, encouraged GPs to attend the shared training scheme where they completed a work placement with the LAS. 

3.    Effective

a.    Report on all ambulance quality indicators - ambulance services had recently been collaborating to share best practice. 

b.    Standardise hospital handovers including the use of NEWS for the sickest patients - benchmarking had been undertaken.

c.    Develop mortality and morbidity review process - this process was being introduced for the first time. 

 

Members expressed concern that the LAS Quality Report 2016/2017 appeared to include very little in the way of statistics to back up performance or to illustrate improvements.  In the absence of data, it was difficult for the Committee to gauge whether the report reflected activity or impact/change. 

 

Although the Committee was advised at the meeting that the response rate to the staff survey was over 2,000, the bullying and harassment feedback levels were very worrying.  Ms Sloper noted that the survey was anonymous and claims of bullying and harassment were not necessarily being reported so that they could be investigated.  To assist staff in reporting instances of bullying and harassment, the grievance process had been made easier.  In addition, the LAS had employed a full time member of staff to focus on bullying and harassment.  This officer had coordinated workshops and a vast amount of training for staff to explain what bullying and harassment actually meant.  This was a huge cultural piece of work.  Mr Ian Johns, LAS Assistant Director of Operations, advised that 70.7% of Hillingdon LAS staff had responded to the staff survey whereas the LAS average was 44.2%.  Of these respondents, none had experienced any physical violence. 

 

Ms Sloper advised that the LAS had just been awarded a significant grant from the Cabinet Office to develop (and increase the number of) Community First Responders.  Community First Responders were emergency responders that were attached to stations but who were on call from home.  This project had just commenced and would focus on recruiting from BME communities in areas of significant health inequalities. 

 

Members noted that The Hillingdon Hospitals NHS Foundation Trust Quality Account 2016/2017 report had stated that the introduction of Band 7 nurse navigator posts had improved the monitoring of LAS queues and LAS handover times.  Mr Johns advised that there had been a significant improvement: in March 2016, there had been 290 hours lost by LAS staff having to wait over 15 minutes; in March 2017, this had reduced to 193 hours. 

 

There had been a 20% increase in blue light activity but the closure of Ealing paediatrics had had a minimal impact on LAS transfers to Hillingdon Hospital.  Mr Johns would provide Members with information about what had caused this 20% increase.

 

Hillingdon Clinical Commissioning Group (HCCG)

Ms Caroline Morison, Chief Operating Officer at HCCG, advised that HCCG was part of a federation of three CCGs (Brent, Harrow and Hillingdon) with a Director of Quality and Safety who was responsible for the quality agenda across all three boroughs.  In addition, each borough had an Associate Director of Quality and Safety who led on the quality agenda locally and there were designated posts for dealing with the LAS and central contracts.  Ms Claire Lamb, HCCG's Associate Director, Quality and Safety, presented the CCG’s approach to monitoring the quality of services delivered by its providers.

 

HCCG monitored a number of quality issues across the boroughs:

·         Contractual requirements such as standard conditions and the quality schedule - there was a core schedule for each provider which included requirements for reporting serious incidents, workforce issues, physiotherapy waiting times and maternity care.

·         CQC inspection findings - HCCG monitored the Trust action plans to ensure that progress was being made. 

·         Intelligence from other sources such as Healthwatch and complaints - these issues could be in relation to things like individual funding requests for treatments such as fertility. 

·         Quality assurance visits - Ms Lamb had visited A&E, maternity and Mount Vernon to have discussions with staff and patients to then provide feedback to the Trust. 

·         Local meetings with providers - HCCG met with CNWL and THH on a monthly basis.

·         Contractual meetings of the Clinical Quality Review Group - these meetings were structured around the conditions within the quality schedule and looked at the progress made and action taken. 

·         Serious incident reporting - as there had been a reduction at Royal Brompton and Harefield NHS Foundation Trust, the risk lead had looked at learning from the actions that had prevented incidents from reoccurring.

 

Ms Lamb advised that the Federation produced a dashboard that covered all providers in North West London based on the quality KPIs in contracts.  This provided the Federation with the ability to benchmark providers. 

 

Members were advised that, from 1 April 2017, HCCG had taken on complete responsibility for commissioning primary care.  Action was now being taken by HCCG to try to embed quality. 

 

RESOLVED:  That:

1.    the Democratic Services Manager solicit feedback on the format of the two Quality Account meetings;

2.    Mr Johns provide the Committee with a breakdown of the causes of the 20% increase in blue light activity in the Borough; and

3.    the presentations be noted.