Agenda item

(Councillor Ian Edwards in the chair)

 

QUALITY ACCOUNTS

 

It was acknowledged that the timing of this meeting had been a little premature with regard to consideration of the Trusts' Quality Account reports.  As such, those present were asked to provide Members with any information that was available in relation to emerging priorities that the Trusts would be including in their final Quality Account reports.  Committee Members would be considering the final reports outside of the formal meetings to then formulate and submit the Committee's response. 

 

Hillingdon Clinical Commissioning Group (HCCG)

Ms Caroline Morison, Chief Operating Officer at HCCG, advised that, as a commissioner, HCCG was not required to produce a Quality Account report.  However, the organisation did hold quality group meetings to review quality with its service providers. 

 

Central and North West London NHS Foundation Trust

Ms Kim Cox, CNWL Borough Director for Hillingdon, advised that a Trust wide stakeholder meeting had taken place on 9 March 2018 to discuss the quality priorities for 2018/2019.  Emerging mental health priorities for Hillingdon had included greater patient involvement in care planning and decision making.  It was likely that the Committee would receive the top level information within the next two weeks and the final version of the Quality Account report by mid-April 2018. 

 

Section 136s had been a recurring issue and the number had trebled in the last two years.  Work was underway with the Accountable Care Partnership (ACP) and colleagues in the Council's Older People's Services

 

The Hillingdon Hospitals NHS Foundation Trust (THH)

Mr Imran Devji, Director of Operational Performance at THH, advised that THH had held an engagement event with governors and members of the public.  This event had resulted in a number of suggested priorities for 2018/2019 which included: the discharge process, dementia and the administrative processes around clinics and appointments.  It was anticipated that the final report would be circulated in April 2018. 

 

It was suggested that delayed handover between LAS and THH be considered as a priority for the Trust in 2018/2019 as, when this process was disrupted, it impacted negatively on residents. 

 

Royal Brompton and Harefield NHS Foundation Trust (RBH)

Mr Nick Hunt, Director of Service Development at RBH, advised that the Trust's focus during 2018/2019 would be around day of surgery admission and casework as it was important to not lose the quality of the service by reducing a patient's length of stay.  The new radial lounge would enable angioplasty patients to have same day discharge. 

 

The London Ambulance Service NHS Trust (LAS)

Mr Ian Johns, LAS's Assistant Director of Operations - North West Sector, advised that the Trust was currently finalising its Quality Account report which looked at patient safety, patient experience and casework.  It was anticipated that the report would be ready for circulation in late March/early April 2018.  It was noted that some of the 2017/2018 priorities would be rolled over to 2018/2019 and that there would also be the inclusion of some new priorities. 

 

A new database, which kept track of hundreds of cases that had been identified as near-miss events or where review was required, was currently bedding in at the LAS.  Hospital handovers had also been identified as an area for improvement and Mr Johns thanked THH for the help that they currently provided the LAS in this regard.  He also noted that a new pan-London maternity model would be introduced in the near future. 

 

HEALTH UPDATES

 

Hillingdon Clinical Commissioning Group (HCCG)

Ms Morison noted that HCCG was likely to reach its 2017/18 financial target.  The organisation had been tasked with achieving £14m in savings and had worked hard to be on course to achieve £11m.  It was noted that HCCG had other budgets which would be used to meet the control total. 

 

Ms Morison advised that, although 2018/19 was likely to be challenging, meeting HCCG’s financial targets in 2019/20 would be less difficult.  HCCG had been allocated an additional £3m towards its 2018/19 QIPP target and plans were already in place to achieve £14.7m of the £15m target, with much of the associated work already underway.  Work had been undertaken to look at reducing commissioner spend whilst also reducing provider costs. 

 

An assurance process had been undertaken regarding Accountable Care to provide assurance to commissioners, and the system collectively, that the partners were on track to deliver.  Progress had been made to reduce the length of hospital stays by improving the discharge process and the Care Connection Team (CCT) had helped to slow the rate of non-elective admissions (the CCTs supported those aged over 65 to stay at home and staff were able to prescribe).  All hospital patients were reviewed on a daily basis to ensure that action was taken to get patients home as soon as possible.  To this end, the partnership, engagement and systems work had been going well in Hillingdon and, in 2018/19, further work would be undertaken to see what additional actions could be taken through Accountable Care to improve pathways.

 

The musculoskeletal pathway was being redesigned and consideration was being given to the multiple access points and how this could be transformed into a more integrated service with a single access point.  It was anticipated that this work would help to manage the duplication across acute services, community services and the voluntary sector.  HCCG had been liaising with Healthwatch Hillingdon to take this forward. 

 

HCCG had been participating in collaborative working to assess how the eight CCGs in North West London worked together.  It was noted that the eight CCGs would now have a single Accountable Officer and a single Chief Finance Officer.  Ms Morison advised that the CCGs would remain sovereign accountable organisations at a local level for now but that they would gain opportunities to work collaboratively. 

 

Unlike many other CCGs, HCCG had a direct relationship with Hillingdon Hospital.  However, this would not prevent the eight CCGs from sharing best practice. 

 

With regard to the provision of GP services in Heathrow Villages, Ms Morison advised that HCCG had undertaken a procurement exercise and would be in a better position to share more information in nine days.  The availability of estate to house the GP provision had been a challenge but a potential solution had been identified.  It was likely that further information in relation to this development could be shared in the next couple of months. 

 

Redevelopment work was being undertaken at the Yiewsley surgery.  It was noted that this premise had been designated as a training practice and that there would be an increase in the number of GPs there.  It was thought likely that a number of GPs that trained there would stay with the practice after they had completed their training.  It was anticipated that there would be an increase in patient list size at the two practices on the Yiewsley site and work was being undertaken to improve the reception area to draw more patients in.  Any residents experiencing any issues in registering with a GP at this site (or anywhere) should contact HCCG and NHS England. 

 

GP recruitment and retention had been a challenge nationally.  Dr Veno Suri, Assistant Vice Chair at Hillingdon Local Medical Committee, advised that this situation was likely to worsen as senior and more experienced GPs reached retirement if newly trained GPs did not stay in the Borough (in the last year, two of the twelve newly trained GPs stayed in the Borough, it had been only one the year before).  As such, consideration had been given to how the positions could be made more attractive.  For example, there were more opportunities to work part time and there had been an increase in the number of women coming into general practice resulting in an under recruitment of male GPs.  Consideration was also being given to the development of Locum Chambers in Hillingdon (similar to that in Harrow which was led by the Harrow Confederation of GPs) and the creation of innovative GP posts (for example, visiting care homes). 

 

Dr Suri noted that the Clinical Pharmacists Scheme had been welcomed by GPs as it reduced their workload and increased the face-to-face time that they spent with their patients. 

 

(Councillor John Riley in the chair)

 

The Hillingdon Hospitals NHS Foundation Trust (THH)

Mr Devji advised that THH staff had been working really hard over the winter period to maintain services at the hospital.  Although there had been an increase in the number of cases of Clostridium Difficile identified by the Trust, these had been mainly as a result of incidental findings.  Cases of MRSA that were attributable to the Trust were low (0.8 cases per 100,000 bed days in the year to date) but this had been slightly higher than the 0.6 benchmark.

 

The Emergency Department (ED) had been built to accommodate 145 Type 1 patients and 190 Type 2 patients.  However, the actual position saw around 190 Type 1 patients and 250 Type 2 patients which equated to an increase of 31% - total numbers could sometimes be as high as 500 patients which meant that overcrowding became an issue.  As such, the Trust was routinely looking at how the service could be improved to cope with this level of activity.  To this end, THH had successfully bid for £1.5m Department of Health capital funding towards refurbishment of the ED, the total cost of which would be £2m.  It was anticipated that this refurbishment work would be key in improving emergency care services in Hillingdon in time for next winter (2018/2019) and would include a clinical decisions unit, additional cubicle space, dedicated ambulance space to prevent delays for the ambulance crews and an additional seven major spaces.  The Urgent Care Centre would be included in this refurbishment project. 

 

Three hubs had been set up across Hillingdon and were now live.  This meant that residents were able to pre-book medical reviews in the evenings and weekends.  Although this service was currently underused (especially at the weekend), usage had been increasing.  Mr Graham Hawkes, Chief Executive Officer at Healthwatch Hillingdon (HH), advised that HH had undertaken a survey between October 2017 and January 2018 with residents in relation to this extended hours provision.  Although the resultant report had not yet been published, he confirmed that only 8% of respondents had been aware that the service existed and that GPs were not necessarily raising awareness amongst their patients.  It was acknowledged that it would take time to raise awareness of the service amongst GPs as well as patients and that generally patients would prefer to visit a GP rather than A&E.

 

It was noted that, to cope with current high level of demand, THH had had to open up a number of escalation beds.  The cost of this additional capacity would be better spent up front on staff to resource the new ED facility.  This would ensure the provision of safe and dignified care for patients and would be good for staff morale.  Mr Devji acknowledged that there was a risk that the new ED would attract additional patients but was unlikely.  However, the new housing developments in the Borough had already prompted a 10% increase in the population which had been reflected in the number of patients seen at the hospital.  If there was an unexpected increase, patients could be diverted to alternative care pathways which would be collocated. 

 

The Trust had analysed the quarter three results of its Friends and Family Test (FFT) and inpatient survey (approximately 35,000 people responded to THH’s various surveys each year):

·         99.7% (391 respondents) had provided a positive response to quality of treatment and care (there had been one negative reference (0.3%)); and

·         99.8% of respondents (854) felt that staff were professional and competent (there had been two negative references (0.2%)).

 

THH’s Our People Strategy 2017-2022 was now available on the front page of the Trust’s Intranet site and set out how THH’s CARES Values were at the heart of everything they did.  The document set out the Trust’s position with regard to education and training, recruitment and retention and where it wanted to be in the future.  It also set out a pathway to building a high performing workforce, engaging staff and living the values for the patients.  To help with recruitment, retention and investing in its staff, THH had been working with Brunel University and CNWL to develop the Brunel Partners Academic Centre for Health Sciences.

 

Whilst THH did not face the same level of challenge as GPs, the Trust had managed to recruit consultants but it was sometimes difficult to recruit acute physicians with experience.  THH had been working collaboratively with other Trusts to drive retention initiatives and consideration was being given to rotational programmes for work streams, family friendly policies and increasing the number of Health Care Assistants completing the Band 4 training course to become Nursing Associates.  Over the last couple of years, consultants had also been going out into the community more to work with GPs and nurses.  It was suggested that consideration be given by the Committee to this issue being the subject of a future scrutiny review. 

 

Mr Hawkes noted that the THH staff survey had been published in the previous week.  The responses had highlighted some areas of concern which included bullying and general unhappiness with the pressure that staff experienced.  Mr Hawkes suggested that these issues be included in the Trust’s 2017/2018 Quality Account Report.  Mr Devji hoped that the implementation of the Trust’s Our People Strategy would address these issues so that staff started to feel a difference.  In addition, staff now had access to a Freedom To Speak Up Guardian who was used to take immediate action and support the member of staff through the process.  Daily patient safety huddles were also strengthening the staff voice by enabling them to raise issues of concern. 

 

Mr Devji advised that THH maintained an open and transparent relationship with the regulator.

 

The Care Quality Commission (CQC) had undertaken an inspection between 6 and 8 March 2018, focussing on Hillingdon Hospital.  The CQC had thanked all of the staff for their help in facilitating the visit.  Ms Vanessa Saunders, THH’s Deputy Director of Nursing and Patient Experience, advised that the CQC would be undertaking a number of unannounced visits and would then follow up with a review of ‘Well led’ at Hillingdon Hospital at the end of April 2018.  The CQC had also requested additional supporting information. 

 

THH had worked with the UCC and LAS around non admissions.  This work had looked at reconfiguring existing pathways and building new ones to support patient flow.  The assessment area was fully functional with clinics from 8am to 8pm at the weekend and extended hours midweek. 

 

Central and North West London NHS Foundation Trust (CNWL)

Following on from a suggestion made by the Committee, Ms Cox advised that all CNWL staff were now signed up to the “My name is…” campaign with just one team left to train.  It was suggested that the campaign should be rolled out to all public sector organisations, not just the health service.

 

It was noted that getting positive responses from the FFT was not particularly easy when looking at mental health services.  Whilst there had been 918 responses received in relation to Hillingdon Community Health (HCH) there had been 109 for Hillingdon Mental Health (HMH) and 120 for CAMHS.  However, 95% of all respondents would recommend the services provided by CNWL (96% for HCH, 86% for HMH and 83% for CAMHS).  As a result, meetings with HMH patients had been planned for April 2018 to establish how the FFT response from HMH patients could be improved as there seemed to be a general feeling of survey fatigue. 

 

CNWL had taken action to learn from negative feedback received through the FFT.  This feedback included receiving an appointment letter after the appointment date had passed, being passed between services without communicating the reasoning clearly to the patient and the facilitation of shop runs for patients without leave. 

 

Improvements had been made to the CAMHS service over the last year which included closer working with schools.  It was anticipated that the transitional age moving from 18 to 25 would not impact significantly on the Trust.  CNWL currently already had a 14-25 psychosis team and, although patients would still transition to adult community services at 18, the transition would be tailored appropriately for each patient. 

 

Hillingdon had been leading the way with regard to peer led support (PLS) work with the inclusion of a PLS worker (that had lived experience of mental health services) in every relevant team.  A magazine, ‘Hope in Hillingdon’, had also been produced by CNWL mental health patients.

 

In the last year, investment had been undertaken in the Rapid Response Home Treatment Team to reduce the number of mental health patients escalating and ending up in A&E.  It was also hoped that a mental health room would be included in the redevelopment plans for the ED at Hillingdon Hospital. 

 

Next year, further work would be undertaken in relation to the CCTs with wrap around support and s136s where CNWL would be working with the LAS (the Metropolitan Police Service (MPS) would also need to be involved).  It was noted that recent changes in the MPS had led to the withdrawal of the hospital-based police officer.  Ms Cox noted that the conversion of patients from the s136 suite to hospital was less than 10%. 

 

With regard to palliative care, the out of hours service support line was now available but was still in its infancy.  Joint working was also being undertaken with school nurses. 

 

It was recognised that the different health organisations in the Borough knew eachother well and worked well together.  As such, it was suggested that this good working relationship be highlighted when trying to recruit new staff to the Borough. 

 

Royal Brompton and Harefield NHS Foundation Trust (RBH)

Mr Hunt advised that the Trust had collated sources of patient experience and thoughts into The Patient Experience Annual Report 2016-2017 document which had been included on the agenda.  RBH had been through its own patient-reported outcome measures (PROMs) process which it would continue to work on.  The rb&hArts Program had also been woven into the work of the Trust. 

 

It was noted that the top five improvement themes identified by patients related to: information and communication (478), waiting (386), food (384), care (general, attitude) (178) and cleanliness/toilets/facilities (104).  One of the challenges in relation to information and communication was where a young clinician relayed bad news to an elderly patient.  To this end, further training had been identified to address this issue (the ‘Barbara’s Story’ film had previously been used by RBH as a training aid for staff to see what it was like to be a patient). 

 

With regard to cleanliness, it was noted that, whilst the standard of cleanliness on the wards was very high, not everyone using the public areas maintained the same high levels of hygiene.  However, the Trust used a rapid response cleaning team to deal with any cleanliness issues once they had been reported. 

 

It was noted that the Kings Fund had undertaken a significant amount of work about five years ago in relation to handling deaths within different cultures.  Mr Hunt advised that it was important to ensure that the staff continued to learn and train. 

 

Members were advised that, on 30 November 2017, NHS England had met and accepted RBH’s and Leicester’s positions and actions plans.  RBH had since been in conversations with Guy’s and St Thomas’ NHS Foundation Trust to move to a new location on the south side of Westminster Bridge within the next ten years.  Although the news had not been welcomed by some, Mr Hunt advised that the Trust would continue things such as lung surgery for the Royal Marsden and the services provided would remain the same (just delivered from a different site).

 

The London Ambulance Service NHS Trust (LAS)

Mr Johns noted that approximately 45% of all LAS staff were female and that this was reflected in the front line paramedics and other clinical staff.  The Chairman of the Board was also driving for the diversity of the community to be reflected amongst the staff.  Health Education England had provided a £500k grant to the LAS to go into schools to show pupils what it was like to work for the ambulance service.  Funding was also available for the paramedic training.  Staffing in NWL was at 93% and staff turnover levels had decreased.  Generally, the LAS in Hillingdon and in NWL was doing well. 

 

Concern was expressed that there had been a cohort of new staff recruited that had left the LAS soon after.  Mr Johns was unaware of this incident and would be unable to comment unless he could see the report.  He did note that, in NWL, 3% of the leavers between September 2016 and September 2017 had returned to Australia. 

 

Members were advised that there had been a spike in the number of 999 calls made to the LAS in December 2017 - during this same period, the number of calls to MPS had decreased.  This period on the lead up to Christmas had been very busy with things such as respiratory issues. 

 

Calls that came to the LAS from the North West London (NWL) NHS 111 provider had been causing some problems due to their volume.  The LAS had been working through the CCGs and the STP to reduce these.  It appeared that recruitment to NHS 111 had been a challenge in NWL with calls being answered by a non-clinician (calls for an ambulance had to be dealt with by a clinician).  It was noted that the LAS already provided the NHS 111 service in South East London and had recently been successful in bidding for the service in North East London. 

 

Work was also underway to address the number of elderly falls in Hillingdon, which was the highest in NWL.  Ms Emily Grist, the LAS’s Stakeholder Engagement Manager (SEM) in the North West, advised that consideration had previously been given to a ‘falls car’ a couple of years ago.  As the number of falls in Hillingdon was high, the ‘falls car’ proposal would now be taken forward.  Members were advised that a large number of the falls calls received were for individuals that were stuck on the stairs or toilet or who were uninjured and just needed to be picked up off the floor.  However, these individuals could be waiting for hours for an ambulance to arrive as the calls were deemed to be of low priority (there were special measures in place to deal with vulnerable people in cold weather).  In many cases, simple home adaptations would prevent these calls and maintain independence. 

 

It was noted that, in the last twelve months, the number of LAS conveyances to Hillingdon Hospital had remained about the same month on month.  However, ambulances were not the only way that patients arrived at hospital. 

 

Ms Grist stated that the Trust had been working with palliative care teams to set up an advice line that would benefit patients and the LAS.  The Trust had not previously had access to this before. 

 

The LAS had also been working with CNWL in relation to mental health and ensuring that patients were delivered to the right service.  Feedback to date had been mixed but the service had only been launched in December 2017.  The LAS was also making more referrals to the Rapid Response Team (RRT) in Hillingdon than in any other borough.  RRT staff had accompanied LAS staff on the ambulances and completed the LAS training.  Likewise, LAS staff had been out with the RRT staff. 

 

With regard to patient handover at Hillingdon Hospital, a task and finish group had been set up to look at what could (and could not) be achieved.  This group was still in its infancy, establish only three weeks previously. 

 

Only 5-10% of high intensity users of the LAS service actually needed to be conveyed to hospital.  As such, the LAS had been working with mental health teams to reduce this contact with a two weekly meeting to update on progress.  However, this was a difficult situation as the Trust was dealing with patients that had complex needs. 

 

As the LAS did not have access to District Nurses, the Trust tended to refer patients to the UCC at Hillingdon Hospital.  Work was currently underway to address this.  The LAS was also working with GPs to advise care homes of options (so the care home would call the GP for an appointment (where appropriate) rather than calling for an ambulance).  Bespoke training was being provided to build the confidence of these care home staff and develop proactive care planning. 

 

The most recently undertaken LAS staff survey had seen its highest completion rate ever with approximately 50% of staff responding.  Hillingdon was the Trust leader in terms of numbers completing the survey and indicated supportive management and no bullying by management.  However, assaults on staff by patients continued to be an issue. 

 

The CQC had previously rated the LAS as ‘Requires improvement’.  Mr Johns noted that the CQC had been inspecting the LAS over the last couple of weeks and would be back on 21 and 22 March 2018 to look at the ‘Well Led’ component.  LAS staff had worked tirelessly to improve the situation for the Trust.  Members noted that there had been a significant change in the LAS over the last four years with regard to engagement and that there had been a real focus on leadership and innovation. 

 

It was noted that a lot of the work undertaken by the LAS was social rather than clinical (for example, elderly, mental health, drug/alcohol related).  In many of these situations, hospital was not always the best place for these individuals to be. 

 

The LAS had specialist teams which would deal with every eventuality.  Mr Johns advised that, following the recent nerve agent incident, anti nerve agent had been distributed to LAS staff and would be placed on every ambulance as soon as possible. 

 

Healthwatch Hillingdon (HH)

Mr Hawkes noted that, in the survey undertaken by HH with residents in relation to the extended GP hours provision, 95% of respondents had indicated that they would rather see a GP face-to-face and that they did not want to go to the UCC or A&E.  The survey had also indicated that Hillingdon residents would like appointments in the morning at the weekend but that there was not so much demand for the afternoons.  Communication about the service had been disappointing in that it had not commenced until after the service had been launched.  Analysis of the survey would be reported to the GP Confederation so that the provision could be adjusted accordingly.  However, it was acknowledged that NHS England had insisted that the provision be 8am to 8pm on Saturday and Sunday. 

 

Young Healthwatch had recruited 19 young people aged between 13 and 22 who had taken part in peer-to-peer engagement.  A further 18 young people would be interviewed in the near future. 

 

A mental health wellbeing programme had been delivered at Barnhill Community High which looked at identifying pupils who self harmed.  The school had taken on a holistic approach to mental health and HH was now looking to extend the programme to other schools, subject to obtaining additional funding. 

 

Mr Hawkes advised that there had been health related procurement exercises undertaken for services in the Borough that the Committee and Hillingdon’s Health and Wellbeing Board had been unaware of.  He had raised this at the Health and Wellbeing Board meeting the previous week to highlight the problem that had arisen with regard to the Whittington being unable to start a new service contract in Hillingdon and the current service provider having to have its contract extended.  NHS guidance made the presumption that the current NHS premises should (not ‘must’) be offered to the incumbent provider but, in this instance, this had been refused.  Concern was expressed that there would be no incentive for the existing provider to cooperate if this lack of cooperation resulted in an extension to their contract.  There had been a similar issue in relation to the sexual health contract about a year ago.  It was anticipated that HCCG would be writing to NHS England on Hillingdon’s’ behalf about this issue. 

 

Mr Hawkes questioned what local oversight there was in relation to services provided in Hillingdon that were commissioned from outside of the Borough.  It did not appear that a thorough impact assessment had been undertaken – these impact assessments should be brought to the Committee.  It was suggested that this be considered as a future scrutiny review topic. 

 

Members were advised that HH was currently looking for a new Chair and Board Members. 

 

RESOLVED:  That the presentations be noted.