Agenda item

The Chairman welcomed those present to the meeting. 

 

Central and North West London NHS Foundation Trust (CNWL)

Ms Maria O’Brien, Divisional Director of Operations at CNWL, advised that the Trust’s full Quality Account (QA) report had been circulated to Members and that the Committee’s response would be due by 3 May 2019.  It was noted that CNWL covered a very large geographical area and that not all of the information included in the report would be relevant to the community and mental health services provided in Hillingdon. 

 

Members were advised that the Trust had retained the same quality priorities for the last three years: patient and carer involvement; and staff engagement.  This continuity had provided a more rounded picture of trends and allowed time to embed changes which would not necessarily happen with a single year snapshot. 

 

Over the last year, a proactive steering group in Hillingdon (comprising service users and carers) had co-designed changes to the mental health pathway, produced a newsletter and created a discharge information booklet.  Service users had been involved in the recruitment of senior members of staff and there was now a large number of peer support workers in the Borough. 

 

CNWL continued to hold large engagement events with its stakeholders and had held a stakeholder Quality Account event on 1 March 2019.  Insofar as staff engagement was concerned, Members were advised that there had been a qualitative improvement with a big event being held each year for the last three years.  These events had encouraged a bottom up approach to change which staff had helped to shape and develop.  This year, the event had been attended by about 800 of CNWL’s 7,000 staff and the focus had been on wellbeing (for example, physiotherapy, resilience and stress pathways). 

 

Whilst some services within the Trust were fully on board with corporate engagement, there were other areas where it was more alien.  Some service areas that had not previously engaged in a meaningful way, had found the process to be both useful and rewarding (especially in relation to community services). 

 

Ms O’Brien advised that CNWL was a large organisation which afforded its staff opportunities to progress and change career.  This meant that the Trust could become an employer for life.  However, a lot of work still needed to be undertaken as many of the services provided by CNWL were subject to re-procurement.  This could make staff feel nervous and unsettled about the security of their employment and the morale of staff working in this environment tended to be lower. 

 

Ms Millard advised that exit interviews were undertaken with staff that were leaving a post.  The most common reasons for leaving were in relation to retirement, relocation, promotion and work/life balance (over which the Trust had some control).  The risk of leaving the organisation was highest in the first twelve months so consideration was being given to the recruitment process to ensure that prospective recruits were fully aware of what the job would entail. 

 

Various projects had been developed across the organisation including a focus on reducing staff turnover.  This work had identified that up to 25% of new Band D recruits across London left CNWL within their first year of employment.  Action had been taken which had resulted, over the last three or four months, in a reduction in the number of new Band D recruits that stayed in post after twelve months.  Around three years ago, the baseline in Hillingdon had been higher than for the rest of London (approximately 30%) but this had now reduced to around 15.9% with figures for new starter resignations also reducing.

 

Ms Katy Millard, Director for Community Services at CNWL, advised that a New Starter Engagement Roadmap had been developed to help managers to ensure that new staff felt welcomed into the organisation, engaged, motivated and valued.  The roadmap had been distributed to managers and consideration was being given to developing a similar roadmap for staff that had been newly promoted. 

 

Ms O’Brien noted that Hillingdon’s performance was better than the overall Trust performance.  Productive collaborative work had been undertaken with carers in relation to pressure ulcers and Hawthorne Intermediate Care Unit (HICU) patients were being more proactively engaged in planning their discharge.  Feedback on services such as Hillingdon Rapid Response, CAMHS and Community Health 0-19 had also been positive.

 

Members were advised that CNWL had recently been reinspected by the CQC and that the resultant report was likely to be positive. 

 

Although new quality priorities had been identified for 2019/2020, effort would be made to monitor and to continue work around the old priorities.  It was anticipated that the following four new quality priorities would be retained as a three year programme:

1.    Reducing falls – multifactorial assessment for inpatients over 65.

2.    Managing the deteriorating patient – reduce the risk to patients’ physical health by ensuring early identification and prompt management of deteriorating health.

3.    Reducing violence and aggression for staff and patients – reduce incidents of physical assault involving staff and service users (Trust-wide) by 30% by 31 March 2022.  Members were advised that violence and aggression towards staff and patients was the most commonly reported clinical incident at the Trust.  The issue was also significant in non-mental health services and included racial abuse.  A Violence and Aggression Strategy had been developed and staff were encouraged to not accept this behaviour, even in mental health services.  This message had been reinforced with patients and there had subsequently been an increase in the number of incident reports being made and follow up work being undertaken.

4.    Improving the quality of supervision – achieve consistency in the recording and quality of supervision.  Action would need to be taken to apply some consistency as, currently, there was no way to track the quality of the supervision being provided to staff.

 

It was noted that the Trust’s target of 70% of staff recommending it as a place to work had not been achieved in 2017/2018 (58.05%) or 2018/2019 (58.48%).  Ms Millard advised that, whilst there were strong, long-standing teams in Hillingdon, this was not necessarily the case across the whole of London.  In addition, a lot of work had been undertaken to follow up on reports of staff being abused and workload was an issue that might need to be addressed. 

 

When looking at the service areas of the Trust as a place to work, Hillingdon’s community and mental health services performed better than all other areas.  It was suggested that the implementation of new models could sometime affect morale and that it was therefore important to get manager level training right.

 

Members congratulated CNWL for the level of meaningful engagement that the organisation had achieved.  The most frequent feedback received from this engagement was in relation to CAMHS waiting times and continuity.  Action was being taken in relation to autism pathways improvements but Young Healthwatch Hillingdon had found that waiting times were still an issue with young patients regularly asking when they were going to get some support.  Insofar as continuity was concerned, it was noted that there were sometimes issues around the responsibility split between primary and secondary care and there was also a limited third sector service provision in the Borough.  Mr Gary Collier, the Council’s Health and Social Care Integration Manager, advised that the Citizen’s Advice Bureau and other organisations were commissioned to provide some services in the Borough and he would forward details of these services to the Democratic Services Manager for circulation to the Committee Members.  Investigations were also underway with regard to establishing a crisis café but no further information was currently available. 

 

Dr Steve Hajioff, the Council’s Director of Public Health, advised that third sector involvement was a matter for consideration by commissioners and would become increasingly important for Hillingdon Health and Care Partners.  As collaboration became more commonplace, it would become increasingly important to bring in third sector organisations to help cover off some of the risks. 

 

Dr Veno Suri, Vice Chairman of the Hillingdon Local Medical Committee, noted that patients’ health could be affected by debt and housing issues.  As such, the provision of signposting was very helpful to GPs.  Dr Suri noted that access to CAMHS services continued to be a challenge at a local and national level. 

 

Ms O’Brien advised that the Learning from Deaths data covered both community and mental health services.  Whilst the services may not have been able to prevent the deaths, the Trust sought learning opportunities to raise awareness wherever possible.  Members were assured that Hillingdon was in the lower quartile of suicides of patients known to CNWL services.  The Trust was also a member of the Zero Suicide Alliance which focussed on training and attitudes.  Whilst it was still early days, the Trust wanted its staff to be more mindful and aware.  Further detail of the progress being made would be provided at a future meeting.  Ms O’Brien advised that the Medical Director oversaw the learning from deaths and the learning disability deaths were reviewed externally.  Dr Hajoiff noted that there had been some transformational work undertaken over the last 6-7 years to tackle suicide risks. 

 

It was noted that one patient under the age of 16 had been admitted to adult facilities in 2018/2019.  Although no patients under the age of 18 should be admitted to an adult facility, this particular patient had already spent 4-5 days in A&E.  As such, it was deemed safer to move the patient to the adult facility where there were additional staff.  Members were advised that an inpatient unit had been opened next to the Chelsea and Westminster Hospital in November 2018.  A six-bed children’s unit would be opened later this year for learning disabilities. 

 

Ms Millard noted that there had only been a small number of complaints made in 2018/2019 relation to the services provided by CNWL.  Every complaint was taken seriously by the Trust and progress was tracked.  Although complaints tended to be in relation to communication, Ms Millard would provide Members with a breakdown of the complaints received in 2018/2019.

 

With regard to clinical effectiveness targets, Ms O’Brien was unsure which were set by national audit and which were set locally.  Dr Hajioff advised that the creation of clinical effectiveness targets was a challenge as some end point clinical outcomes could not be used as they were affected by more than one factor. 

 

The Committee recognised that CNWL had made significant improvements over the years. 

 

The Hillingdon Hospitals NHS Foundation Trust (THH)

Mr Dean Spencer, Interim Chief Operating Officer at THH, advised that the hospital had been in an increasingly difficult position over the last 2-3 years.  Following the appointment of a new Chief Executive on 26 November 2018 (Ms Sarah Tedford), there had been significant changes to the senior management team with only two members of the team having been in post for more than 3 months.  Members were also advised that the Trust Chair (Mr Richard Sumray) had stepped down on 29 April 2019 and Ms Liz Pace had been appointed as the Interim Chair. 

 

Mr Spencer had previously worked with THH as a regulator from NHS Improvement.  The recruitment process for the substantive Chief Operating Officer post was currently underway.  THH had struggled with its budget / control total and operational standards had not been met or had declined over the last two years, for example, the four hour A&E target.  Although THH had achieved 81% against the 4 hour A&E target, the national standard was 95%. 

 

In the last year, THH had had a £26m overspend which was clearly not a sustainable position.  An £11.4m savings requirement had been put in place for the current year with approximately half of the savings having already been identified.  Achieving these savings would held to stabilise the Trust’s finances this year so that consideration could then be given to implementing a transformation agenda to deliver sustainable improvements.  The work of Hillingdon Health and Care Partnership had helped to implement radical changes and would help to achieve the savings needed.  It was hoped that, with continued effort, the Trust would be back in balance by 2024.  With regard to payment for the services provided by THH, this was determined by the block contract with commissioners and consideration would need to be given to what services would not be provided. 

 

Six objectives had been set as the 2019/2020 Foundations for the Trust: Quality; Workforce; Performance; Finance; Well Led; and Partnership Working.  Members noted that the Council had not been listed in the presentation slides as a partner, yet had been a fundamental part of helping THH to move forward.  It was noted that staff were generally very proud to work for THH.  Although some elements of the Foundations were already being delivered, this delivery was inconsistent or not necessarily happening routinely.  It was anticipated that the Foundations would help all of THH’s 3,500 staff to understand what was expected from them.  Mr Turkay Mahmoud, Interim Chief Executive Officer at Healthwatch Hillingdon, urged for the need to ensure that patients and staff were not alienated whilst changes were being implemented and new pathways developed.

 

Concern was expressed that there appeared to be an imbalance between the good work undertaken by the staff and the quality of middle management upwards.  If sufficient supervision and management was not in place, improvements would not be sustained. 

 

The last CQC inspection had seen Hillingdon Hospital rated as inadequate.  The Committee had held a meeting to solely look at the CQC’s report and findings.  Many of the responses received from THH representatives at that meeting had been thought by Members to be unhelpful.  Mr Spencer assured Members that the current senior management team would be able to take the Trust forward.  He noted that Ms Tedford had a good track record with this regard.  Furthermore, it was anticipated that the Governors would appoint a new Chair in the next few months. 

 

Mr Spencer noted that a great deal of work such as tidying had been completed since the CQC inspection had been undertaken.  Although the estate did not provide the best environment, staff did their best in the circumstances.  Following CQC criticism, the new senior management team were regularly visible on the wards at Mount Vernon Hospital and Hillingdon Hospital (on a daily basis) and received feedback directly from the staff. 

 

Members were advised that the Trust was not currently in a position to be able to share its 2018/2019 QA report.  Mr Spencer advised that the report would be sent to the Committee after the Trust Board meeting on 24 May 2019. 

 

It was agreed that, once received, the THH Quality Account report would be circulated to Members for comment outside of the Committee’s meetings.  The Chairman and the Democratic Services Manager would then draft the Committee’s response for submission and inclusion in the final version of the THH report. 

 

Dr Suri noted that patients tended to be less unwell in the warmer months and more unwell in the colder months, creating winter pressures.  He suggested that, to help alleviate pressures on THH in the colder months, information be forwarded to GPs to redirect patients to alternative sources where appropriate.  Dr Suri chaired the Neurology Working Group and suggested that GP access to a neurologist would reduce unnecessary emergency hospital admissions for patients with epilepsy and improve integrated care.  It was recognised that it was less expensive for patients to be seen in the community. 

 

Mr Mahmoud expressed concern that complaints to THH were not being dealt with effectively or consistently.  He noted that one incident that he was aware of was now over eight months old.  Conversely, another complaint submitted to the Trust had received an immediate response.  Standards for dealing with complaints were in place and Mr Spencer believed that generally the team had been doing a good job in dealing with complaints.  He would provide the Democratic Services Manager with contact details for complaint liaison / escalation.

 

Local Medical Committee (LMC)

Dr Veno Suri, Vice Chairman of the Hillingdon LMC, advised that patients would be seeing a big change in service delivery with a push to form Primary Care Networks (PCN) that would collectively provide services to 30k-50k patients.  It was anticipated that this way of working would allow GPs to refer a patient to another practice within their PCN that had a specific expertise.  The PCNs were due to go live in July 2019. 

 

Members were assured that a patient’s GP would remain responsible for the patient and that each practice would be required to provide core services.  Additional services could then be provided by GPs or patients could be referred on to another practice within their PCN.  The PCNs were still in the formation process and it was anticipated that this transformation of services provided in primary care would cost a lot less than if they were provided in secondary care and GPs might be able to provide services quicker than a hospital.  It was noted that the aspiration was that, eventually, every PCN would provide the full offer.  Although there would be no requirement to provide the full offer, it was thought that this would happen and would provide residents with a positive experience. 

 

Healthwatch Hillingdon (HH)

Mr Turkay Mahmoud, Interim Chief Executive Officer at HH, advised that Healthwatch England had commissioned HH to look at the long term plan over the last six weeks.  Two associated workshops would be held the following week.  The available information included ward level data and would feed into a North West London report. 

 

The Chairman suggested that he and the Democratic Services Manager make arrangements to meet with the THH Chief Executive.  This was agreed by the Committee. 

 

On behalf of the Committee, the Chairman thanked Councillor Teji Barnes for her hard work over the last few years.  She would not be sitting on the Committee in the 2019/2020 municipal year as she was due to be appointed as Deputy Mayor for that period. 

 

RESOLVED:  That:

1.    Mr Collier forward details of the third sector support services commissioned in the Borough to the Democratic Services Manager for circulation to the Committee Members;

2.    CNWL provide further detail of the progress being made in relation to the Zero Suicide Alliance at a future meeting;

3.    Ms Millard provide a breakdown of the complaints received in 2018/2019;

4.    Mr Spencer provide the Democratic Services Manager with contact details for complaint liaison / escalation;

5.    the Democratic Services Manager collate the Committee’s comments in a response for inclusion in the CNWL QA report;

6.    the Democratic Services Manager circulate the THH QA report to Members for comment once received and draft a response in consultation with the Chairman;

7.    the Chairman and Democratic Services Manager make arrangements to meet with the THH Chief Executive;

8.    Councillor Teji Barnes be thanked for her hard work on the Committee; and

9.    the presentations be noted.