Agenda item

The Hillingdon Hospitals NHS Foundation Trust (THH)

Mr Imran Devji, Director of Operational Performance at THH, advised that the Trust's regulators had revised its 4 hour A&E access target to 88%.  The Trust had achieved 87.5% in June 2017, missing its target by just 0.5%.  Type 1 performance (the highest acuity) was at 69.7% which was the Trust's best performance for the last 15 months.  It was noted that this target was proving to be a challenge nationally.  Type 3 patients (lowest acuity) were seen in the UCC and could be dealt with more quickly.

With regard to referral to treatment times, THH had delivered 92.2% in June 2017, meeting the 92% target for the fifth successive month.  However, it was noted that referral to treatment times for planned care (GP referrals) was not without its challenges. 

Members were advised that THH had sustained performance by achieving all cancer standards in May 2017 - the June 2017 position was awaited.  With regard to infection control, Ms Vanessa Saunders, THH's Deputy Director of Nursing and Patient Experience, noted that there had been one case of MRSA and 2 cases of C. diff in the year to date.  Root cause analyses had been undertaken and had shown that these cases had not been as a result of a lapse in care.  The C. diff cases had been linked to age and comorbidities. 

Patients were asked to respond to the Friends and Family Test (FFT) when they were discharged from hospital.  In the last year, 33,000 individuals had completed the survey and the results had reflected the challenges experienced in A&E.  The FFT included the ability to include comments (free text) and quarterly analysis of this information had shown that communication and the provision of information were recurring issues, e.g., the need to tell patients how long their wait would be. 

Mr Devji advised that the Trust's £12.9m deficit in 2016/2017 had been offset by £11.3m of accounting benefits which had then enabled THH to gain £6.8m in Sustainability and Transformation Funding (STF), thus resulting in a £5.2m reported surplus for the year.  It was noted that the realisation of accounting benefits was a short term tool to enable THH to access additional funding to offset the deficit.  As it was not something that could be routinely undertaken, Members queried how the Trust would be able to balance its accounts in 2017/2018.  Mr Devji agreed to liaise with the THH Director of Finance to establish when the Trust's planned £8.8m deficit in 2017/2018 would become a surplus.

THH was looking to improve the control of its finances to enable it to deliver on its ambitious plans and to continue to provide patients with a good level of care.  The Financial Improvement Programme (FIP) was a national programme that provided Trusts with expert financial and operational improvement skills.  Hillingdon had been selected as one of 12 Trusts that would be provided with support from FIP to develop a long term sustainable transformation programme. 

Members were advised that two dedicated bays were now available for ambulances to handover patients as soon as they arrived.  A nurse and a senior doctor were designated to these bays to ensure that patients were seen immediately on arrival.  This process had had a positive impact by providing the best possible care for potentially critical patients that were arriving by ambulance.  This had also reduced the pressure of queuing ambulances by releasing ambulance crews earlier to take other calls.  The Committee asked that its congratulations be passed to the staff involved for such a significant improvement in terms of the care for patients and also freeing up ambulance resources. 

Mr Devji noted that the Trust Board had approved the Trust's Strategic Plan 2017-2021 which was underpinned by financial planning.  The Plan aligned THH's activities with those of the North West London Sustainability and Transformation Plan (STP).  As the STP had changed the landscape in which the Trust operated, it was important that THH's longer term efforts were geared towards the new context.  It was thought that the STP would help THH to articulate its ambitions and collate its key strategies in one place. 

The Trust's strategy focussed on five delivery areas: prevention and wellbeing; managing long term conditions; transforming care for older people; improving mental health; and sustainable, quality, safe, acute services.  Targets had been set and measures had been put in place in relation to governance and monitoring. 

Members were advised that the Hillingdon Health and Care Partners (HHCP) Alliance Agreement had been approved by the alliance of providers in April 2017.  This Alliance Agreement would run from April 2017 to April 2018 (when HHCP would run in shadow form) and had been the product of extensive consultation with each organisation within the HHCP.  HHCP would deliver care to those aged 65 and over and activity would be reimbursed from a pooled budget of around £35m. 

Central and North West London NHS Foundation Trust (CNWL)

Ms Kim Cox, Hillingdon Borough Director at CNWL, advised that the Trust had developed a 4-5-6 model to deliver a 0-19 integrated service in relation to community health.  As part of this work, an additional post had been created to support families with children with additional medical needs and, although it had been a challenge, one clinical record had been created for each patient to reduce the need to repeat their history multiple times.  Much associated work had taken place, including: the creation of a new management structure; the alignment of clinical caseloads and the creation of three locality hubs; plans are in placeto develop an out of hours health visiting telephone support line until 8pm; and offering the fully healthy child programme to children in Hillingdon. 

Ms Cox advised that the CQC re-inspection of older adult mental health services which took place in January 2017 had resulted in a 'Good' rating and that all other re-inspections had so far also resulted in 'Good' ratings.  The Community Mental Health team re-inspection in May 2017 had identified improvements and initial feedback had specifically mentioned the turnaround in community mental health teams in Hillingdon.  Once the official CQC report had been published, CNWL would be rerated as an organisation. 

Members were advised that there had been changes to Section 136 in the Mental Health Act.  These changes included:

·         the need for the police to consult mental health professionals if practicable before using s136.  In Hillingdon, the police would often call before bringing a patient in and were starting to call the Single Point of Access for information;

·         police stations being prohibited from being used as a place of safety for those aged under 18.  It was noted that the Committee had previously looked at s136s as part of a review and had been impressed with the Metropolitan Police Service (MPS) leadership at that time;

·         police stations could only be used as a place of safety for those aged over 18 in special "exceptional" circumstances which were described in the related regulations.  It was noted that the police in Hillingdon generally took patients straight to the s136 suite as the custody suite had been removed from Uxbridge Police Station.  Members were keen to be advised of any police cell detentions under s136 as this was outside of MPS policy;

·         the period of detention under s136 had been reduced from 72 hours to 24 hours with the possibility of a 12 hour extension under clearly defined circumstances.  Members were advised that in the last year, there had been only two instances which had exceeded 24 hours. 

Ms Cox would provide the Democratic Services Manager with further information in relation to s136 and pan London information which set out the responsibilities of each organisation.

Hillingdon Health and Care Partners (HHCP) had established a new management structure which would enable a range of integrated HHCP service to operate under a single management arrangement.  CNWL and THH services had been identified as those that would initially benefit from integrated leadership.  This would benefit Care Connection Teams (CCTs), community services Hospital's Integrated Discharge Team and Homesafe. 

There were 15 CCTs in Hillingdon, most of which were now up and running.  These teams took part in weekly or twice weekly 30 minute huddles which also included GPs, hospital and community staff.  It was estimated that each CCT would manage an average of 50 cases.  The core team included: a Guided Care Matron, a Care Coordinator and GP.  The anticipated benefits included: joined up integrated working; ownership and accountability; improved communication; a reduction in admissions and length of stay; better utilisation of services that were matched to the patients' needs; improved patient experience; and improved employee satisfaction. 

Hillingdon Clinical Commissioning Group (HCCG)

Ms Caroline Morison, HCCG Chief Operating Officer, advised that HCCG commenced level 3 delegation of primary care commissioning on 1 April 2017.  The main advantage of this new arrangement was that HCCG would now have greater control of primary care commissioning budgets which could be tied in to support the work undertaken by the organisation for residents.  To achieve the provision of robust primary care services in Hillingdon, HCCG would need to address the challenges regarding any potential gaps in provision within the Borough and the need for recruiting and retaining workforce.  To this end, long term plans were being put in place to identify the needs of the residents to then be able to put the resources in place to meet these needs. 

As part of its primary care commissioning responsibilities, HCCG was leading the process of reviewing personal medical services (PMS) contracts within Hillingdon to reduce variation between practices commissioned on PMS and General Medical Services (GMS) contracts.  The majority of practices in the Borough were on the GMS core contract but there were 9 PMS contracts and 1 Alternative Provider Medical Services (APMS) contract in Hillingdon.  NHS England had initially instigated a review of how many of the services provided through PMS contracts were outside of those provided in the GMS core contract and therefore required a redesign of the contracts.  It was anticipated that the review would look to address the inequality and redistribute excess funds amongst the practices.  Consultation was currently underway and the process would need to be completed by 1 October 2017.  It was noted that there would be a variable impact on practices in Hillingdon and that HCCG would be working closely with all those affected to ensure the stability of service provision.

Members expressed concern regarding the impact of the proposals relating to prescribing practices on pharmacies in the Borough, especially those where there was limited / no GP service provision.  Ms Morison advised that the impact on pharmacies would be minimal and that it could be used by these businesses as an opportunity to play more of a role in things like the minor ailments service.  With regard to repeat prescriptions, there was an overarching need to reduce wastage and, as such, HCCG would need to work with the Local Pharmaceutical Committee regarding communications.  It was likely that the larger chain pharmacies would be impacted more than independent pharmacies in this regard. 

Dr Steve Hajioff, the Council's Director of Public Health, advised that there had been a study of pharmacies in the Borough which had identified those that would be vulnerable as a result of these proposals.  This study had identified a few areas where there were several pharmacies within a very small area and one isolated pharmacy in the north of the Borough that would be vulnerable.  Measures had been put in place to help.

Hillingdon Health and Care Partners (HHCP) was an alliance of The Hillingdon Hospitals NHS Foundation Trust, Central and North West London NHS Foundation Trust, the Hillingdon GP Confederation (which had recently been established to structure services collectively and gain economies of scale) and Hillingdon for All.  It was proving to be an example of great integration and joint working. 

HCCG had finished the financial year with a surplus of £7.764m which was £4.148m higher than planned.  The £4.148m could be rolled forward into the next financial year.  Members were advised that Hillingdon Hospital and Imperial College were within the STP footprint and were unlikely to meet their control totals.  As such, the 8 North West London (NWL) CCGs were currently trying to balance this out between them. 

Across NWL, the 8 CCGs had embarked on a period of engagement on a set of proposals regarding changes to the way that they prescribed in the area.  A three week period of engagement had been undertaken and the feedback received during this period had helped to inform the final proposals being considered by the Governing Body on 14 July 2017.  The Choosing Wisely proposals were:

·         that GPs ask patients if they were willing to buy certain medicines or products that would be bought without prescription;

·         that GPs not prescribe certain medicines and products that could be bought without a prescription; and

·         to reduce waste, patients would be asked to order their own repeat prescriptions.

It was noted that there would be patients that would be treated as exceptions and an equality impact assessment would need to be undertaken.  Ms Morison noted that the NHS was one organisation and each of the PCTs/CCGs had historically been funded differently.  As such, the 8 NWL CCGs were collectively taking responsibility for the NWL sector a whole.

Ms Morison was aware that residents in Heathrow Villages were experiencing challenges with regard to GP provision.  HCCG had been looking to identify capacity in Yiewsley and West Drayton to address the shortfall.  Further work still needed to be undertaken but Ms Morison was cautiously optimistic about finding the right premises and the right services to meet the need.  It was suggested that better structured GP outreach programmes were needed and that HCCG could consider some less traditional venues for service delivery. 

Members were advised that negotiations with the St Andrews developers had ceased.  As such, consideration was now being given to alternative ways of meeting the health needs of the residents moving onto the site. 

Healthwatch Hillingdon (HH)

Mr Graham Hawkes, Chief Executive Officer at HH, advised that the organisation had developed good relations with stakeholders.  Over the last year, HH had highlighted the care of residents in Hillingdon through work such as its reports on maternity services and hospital discharge.  Work had started to implement changes which were now beginning to take effect. 

A stakeholder survey had been undertaken and, although the results were very pleasing, it was clear that there was still more work to be undertaken.  Mr Hawkes noted that not all partners were aware of the range of services provided by HH and not all residents were being reached. 

Looking at the progress made over the last four years, the Committee felt that HH should be congratulated on its achievements.  Mr Hawkes advised that it was becoming a challenge to follow the work through and ensure the implementation of change once the reports had been published.  HH had a proven record of engaging with residents and was now looking at how this could be financed in future.  Consideration was being given to alternative opportunities to generate funds to support HH's work. 

RESOLVED:  That:

1.    Mr Devji provide further information about how and when the Trust's planned £8.8m deficit in 2017/2018 would become a surplus;

2.    Ms Cox provide the Democratic Services Manager with further information in relation to s136 and pan London information which set out the responsibilities of each organisation; and

3.    the presentations be noted.