Minutes:
The Chairman welcomed those present to the meeting.
Royal Brompton and Harefield NHS Foundation Trust (RBH)
Mr Nick Hunt, Director of Service Development at RBH, advised that the full force of the second wave of COVID-19 had not yet been realised. Currently, RBH had 14 patients with COVID-19, 11 of which were on full life support and two of which were at Harefield Hospital on a general ward. By comparison, Mr Hunt noted that there had been about 40 patients with COVID-19 during the first wave. There were also currently 15 patients on ECMO (Extracorporeal membrane oxygenation) as a result of an increase in the number of flu cases.
With regard to the merger of RBH with Guy’s and St Thomas’ NHS Foundation Trust (GST), both Trust Boards had considered and approved the business case. A TUPE exercise would now be undertaken before the planned merger took place on 1 February 2021. Staff had largely welcomed the proposed merger as it would provide them with additional opportunities for career progression as GST was a much larger organisation that also provided community and DGH services. Mr Hunt noted that the Royal Borough of Kensington and Chelsea did not appear to be happy with the proposed merger despite the move resulting in more shared information and the creation of a £2.5bn enterprise.
Other possible benefits of a merger included wider use of a patient administration system (EPIC) and an increase in purchasing power. It was also noted that paediatric cardiac services would move to the Evelina London Children's Hospital which then fulfilled the requirement of the review undertaken by NHSE to collocate services.
Members were assured that the proposed merger would not change what happened at Harefield Hospital and that there might actually be potential for expansion at Harefield if costs of a new build in central London proved prohibitive. This could also be married with the possible transfer of cancer services from Mount Vernon Cancer Centre. Proposals for a new build in central London would take at least 10-15 years to become a reality.
Mr Hunt noted that North West London (NWL) had produced one of the more ambitious Integrated Care Systems (ICSs) in London.
London Ambulance Service NHS Trust (LAS)
Mr Boyd Fisher, Senior LGM for North West London Sector of LAS, advised that, during the COVID-19 pandemic, there had been 24/7 senior management cover to ensure that leadership was visible. There had also been collaboration between the LAS and the London Fire Brigade (LFB). As the LFB had not been as busy during this period, around 300 LFB staff had volunteered to work with LAS. Some LFB staff had paired up with clinicians and driven ambulances which had worked really well and had subsequently been continued but in a scaled down form.
Other volunteers had also come forward to help the LAS with logistics during the pandemic. Many of these individuals had been furloughed and wanted to make best use of their time whilst they weren’t working. From this process, Mr Fisher had gained a new full time business manager.
It had been anticipated that there would be about 50% absenteeism during the pandemic. However, absenteeism had only reached around 30% which had helped to meet the increase in demand during this period. 320 vehicles were usually put out each day; during the pandemic, this had increased to over 500. Despite this increase, there had been an unprecedented performance in relation to response times between 1 April 2020 and 5 November 2020:
· Cat 1: average = 6 minutes (target = 7 minutes)
· Cat 2: average = 12 minutes 29 seconds (target = 18 minutes)
· Cat 3: average = 30 minutes 7 seconds (target = 120 minutes)
· Cat 4: average = 49 minutes 33 seconds (target = 180 minutes)
Demand through 111 appeared to have stabilised and had resulted in a increase in demand on primary care. At the start of the pandemic, a large proportion of the calls received had been in relation to COVID-19 but the message had gotten through that you needed to be unwell to be taken to hospital so as not to overwhelm the NHS. It was noted that, if performance dropped, active area cover could be put in place to locate staff in the most appropriate locations.
It was noted that Harefield Hospital usually ran at about 100 primary cases of heart attack each month. For unknown reasons, this had reduced to 0 per day for the first few months of the pandemic. Emergency attendance at Hillingdon Hospital had seen a reduction of about 50% at the start of the pandemic but there had been pressures in critical care. There had been occasions where critical care had been at capacity and Harefield Hospital had stepped in to help. It was noted that planned care had been reduced to minimal levels during wave 1 but that there were no plans to reduce planned care for the second wave. Trusts had worked collaboratively where they could to ease pressures on the system and this would be increasingly important during the second wave as the organisations would need to manage planned care as well as winter pressures and COVID-19 pressures.
At the start of the pandemic, the supply of PPE had been a little patchy. Although it had not always been possible to maintain supplies from one supplier and PPE had to be acquired from wherever it had been available, there had always been enough.
Improvements had been made at stations and at the staff living quarters. Unlike many organisations, the majority of LAS staff spent most of their time away from base so shift changeovers could sometimes get a little tight with regard to the availability of resources.
Members were advised that the LAS had reduced from 68 sites across London to 41. This reduction had meant that it had been easier for senior management to look after staff welfare and maintain visibility. The stations in Wembley and Ruislip had been closed as they were owned by NHSPS who had requested they be vacated. These had both been let on short term leases and the LAS had known that they would need to vacate in the short to medium term. The staff from Ruislip had moved to the Hillingdon station which was a much better facility.
Mr Fisher advised that the LAS had recognised that parts of its estate were no longer fit for purpose and that there was a greater need for more training rooms and meeting rooms. To this end, plans had been put in place to develop deployment hubs (also known as superstations). The first of these had been planned for Romford and Mr Fisher was pushing to have Hillingdon identified as the second as premises in the area that had previously been financially out of reach as a result of the pandemic, were now becoming much more affordable. It was anticipated that the Romford superstation would be developed within the next 6-9 months and that this would set a template for another 17 sites. A new superstation would then be developed every three months so that they were completed within five years.
Central and North West London NHS Foundation Trust (CNWL)
Ms Vanessa Odlin, Director of Hillingdon and Mental Health at CNWL, advised that the Trust had been considering the impact of COVID-19 on all of its transformation work.
The main focus in relation to community health services was in relation to discharge out of hospital. The Trust would be working with Harlington Hospice and H4All to pilot a two hour urgent response day time visiting service and Hillingdon Home 2 Assess had provided a pathway to get patients home and had been performing well.
Transformation in Hillingdon mental health had seen the introduction of a First Response Service which offered residents assessments 24/7. The Coves, which was a crisis haven, had gone live in Hillingdon and provided a non-clinical evening offer 365 days each year. For inpatient services, the new Central Flow Hub could find suitable beds and was able to support the elimination of out of area placements. The inpatient admission was supported by new investment which embedded the Trauma Informed Approach and the implementation of the See, Think, Act Framework on wards. It was agreed that Ms Odlin would provide an update on the Cove crisis haven at appropriate future meetings.
Planned transformation work in mental health included the development of a One Stop Shop in partnership with the local authority and third sector organisations to create an open access service for Hillingdon residents. Work had also been undertaken to transform open rehab to be able to offer complex community rehabilitation and work had been undertaken with the local authority to deliver complex community rehabilitation and reduce Extra Contractual Referrals (ECRs) for complex rehab. There had been a desire to shift from ward based to community based rehab services and consideration was being given to phasing parallel step up crisis and step down recovery provision by the third sector to prevent long stays on wards.
New processes would be introduced across the system in relation to emergency and urgent access. These processes would support adults with a mental health crisis to help avoid admission to an inpatient unit by focusing on out of hours case management and increasing the use of the crisis coves.
Ms Odlin advised that school nurses had been offering weekly drop in sessions in secondary schools to support young people with their health and wellbeing, signposting them to other agencies as required. To help prevent sudden infant deaths, health visitors were now routinely asking to see where the baby slept so that they could provide individual advice and care planning to parents. Health visitors were also supporting Hillingdon Hospital in the clinical management of babies with prolonged jaundice to ensure that they were referred to a paediatrician within safe timescales.
As a result of the COVID-19 pandemic, health promotion groups were now being delivered via virtual platforms. This meant that service delivery was likely to continue post COVID to support working parents to access these services.
CNWL had achieved the CAMHS 18 week Referral to Treatment (RTT) target for quarter 2 of 2020, although performance had declined during the first half of the financial year as capacity had been reduced to 50% as a result of the COVID-19 pandemic. COVID-19 had also resulted in a steady increase in the number of young people presenting in crisis and had impacted on the out of hours service.
Work was being undertaken to transform the CAMHS service and develop an Integrated CYP (0-25) Early Intervention and Multi-Agency care and support model. CAMHS had been an integrated part of a pilot where the focus had been on early intervention for young people who had not met the priority threshold for core CAMHS. The team had expanded and developed the model to deliver an integrated early intervention response across the whole Borough to meet the new needs and potential gaps in provision. This included extending both KOOTH and Think Ninja services to support the model, which had been running since May 2020 and had funding secured to run it until December 2020.
It was clear that continued action needed to be taken to provide early intervention for young people before they escalated to crisis. Action was also being taken to extend the service provided to young people from 18 to 25 so that the transition to adult services was smoothed.
Members were advised that the performance of the addictions service in Hillingdon had been impressive compared to national targets on some areas.
It was noted that the Section 75 agreement with the Council had been terminated and it was queried how well things had been since then and whether any gaps had appeared in the service. Ms Odlin advised that it was a little too early to tell but that there would always be challenges that would need to be resolved when two organisations were providing support to the same person. It was agreed that further information about how these providers were working together be brought to a future meeting.
Members were advised that the data had not indicated an increase in the demand or referrals for mental services. However, this might be because the full impact of COVID-19 had not yet been realised. Furthermore, there had been an increase in the levels of acuity on wards and a higher number of individuals that had been sectioned. It appeared that there were more people getting poorly before they sought support rather than soliciting support at an early stage. Although CNWL had built relationships with a range of external organisations, Ms Odlin agreed that it would be useful to reach out to organisations such as the CAB and housing associations to provide them with signposting to services should their service users need it. Members were asked to let Ms Odlin know if there were any other organisations that they thought should be contacted.
The pandemic had made the Trust think about who needed face to face access. At the start of COVID-19, approximately 70-80% of services had been provided face to face but IAPT services had been seeing a lot of individuals digitally. However, consideration needed to be given to the needs of staff who had been working from home and the negative connotations that they then might associate with their homes. Ms Odlin agreed to provide Members with an update on this at a future meeting.
Hillingdon Clinical Commissioning Group (HCCG)
Ms Caroline Morison, Managing Director at HCCG, advised that the Hillingdon COVID Hub had been established to bring partners together across the Borough on a daily basis. Actions had been agreed across health, social care, public health, the third sector and broader partners including the police and Brunel University.
Priorities for the Hub included support to the ‘clinically extremely vulnerable’ (previously known as ‘shielded’), expanding the Escalated Care Clinics and delivery of the flu vaccine to vulnerable groups to increase the uptake. Primary care activity had dropped off during the first wave so effort had been focussed on maintaining access to primary care services, in particular childhood immunisations and cervical smears. Practices had been promoting the use of virtual consultations as an infection prevention control measure but face to face appointments were available where there was a clinical or patient need.
Partners in Hillingdon had developed a winter plan with clear KPIs to address pressures in three areas:
· Step up care – integrated urgent response to redirect patients from UTC/ED to primary and community care services where appropriate, integrated with the rapid response service to maximise caseloads. The mental health safe haven (Cove) would also be used from 4pm to midnight to support this redirection work.
· Hospital processes – a focus on same day emergency care pathways, additional bed capacity, criteria led discharge and seven day discharge support; and
· Community discharge – the discharge to assess service would be enhanced by maximising the care hours, third sector support and integrating key pathways such as end of life. Effort would also be needed to ensure sufficient complex care provision in the community through bedded support in care homes and local authority units.
Ms Morison advised that the flu programme for 2020 was the most ambitious to date with a national uptake target of 75% for a number of vulnerable groups by the end of November. In Hillingdon, this equated to over 95,000 residents. Members were advised that there had been higher levels of refusal than previous years so further information was being circulated to stress the importance of vaccination and redress the myths. Refusal rates would usually be around 2-3% but were currently around 5%. This higher rate was thought to be as a result of the change to proactively contacting individuals. It was also noted that uptake levels were 3% lower among those from more deprived backgrounds than for those from the least deprived backgrounds. Lessons learnt from rolling out the flu vaccination campaign would be used for roll out of the COVID-19 vaccination.
Consideration was given to the monitoring of the reasons for refusal. Although this information was being noted anecdotally, it was not being formally recorded. However, the information still provided HCCG with insight into particular areas or myths than needed to be dispelled. Ms Morison welcomed any contacts that Councillors might be able to share to help spread information about the need to get a flu vaccination.
Members were advised that the eight CCGs in North West London (NWL) had voted to become a single NWL CCG from 1 April 2021 in line with the national policy to establish a single CCG within each Integrated Care System. Consideration would now need to be given to a new CCG constitution which would provide for local oversight and accountability through the establishment of eight Borough Committees. These committees would include representation from local authorities, Healthwatch and local GPs and would also include lay members.
Ms Morison noted that the development of local integrated care partnership arrangements was ongoing but that Hillingdon was slightly ahead. Hillingdon Health and Care Partners (HHCP) had already been established so could start to deliver outcomes in a helpful way. HHCP had recently confirmed the appointment of a substantive managing director to take the next stage of work forward.
It was noted that there had been a management reorganisation of the eight NWL CCGs in preparation for the move to a single operating model. It was anticipated that this would help to deliver financial efficiencies as well as provide support to recovery plans within NWL. Ms Morison confirmed the following would comprise the senior team in Hillingdon:
· Brent, Harrow, Hillingdon Chief Operating Officer: Sheik Auladin (currently Managing Director at Brent CCG);
· Borough Director: Sue Jeffers / Richard Ellis (currently Associate Directors for Primary Care at NWL);
· Associate Director Primary Care Delivery: Tarvinder Kalsi (currently Associate Director Primary Care at HCCG); and
· Associate Director Integration and Delivery: Sean Bidewell (currently Associate Director Strategy, Transformation and Planning at HCCG).
To support the integration of health and care services in Hillingdon, transformation programmes would encompass:
· Primary care / neighbourhood development;
· Urgent and emergency care;
· Elective care;
· Children and young people’s services; and
· Mental health, learning disabilities and autism.
Members were advised that discussions had been undertaken locally regarding the news of a COVID-19 vaccine. However, Ms Morison was limited on what information she was able to share other than consideration had already been given to logistics.
Concern was expressed that, in the early days of the pandemic, there had been a dip in the number of patients being screened for cancer. Ms Morison confirmed that the first quarter of 2020/2021 had seen a lag but that cervical screening had caught up somewhat and was ahead of the recovery trajectory. She would forward information on breast screening to the Democratic Services Manager for circulation to the Committee.
It was recognised that there had been significant financial pressure on the whole NWL health system with increasing demand, fewer resources and an older population. Ms Morison advised that during the first six months of the pandemic, instead of setting a budget for the year, HCCG had been required to return to break even each month and send a monthly spend summary to NHS England. During the second half of the year, HCCG had agreed a budget with NWL and had an achievable target to deliver £2m of efficiency savings by the end of the financial year. Mr Jason Seez, Acting Chief Executive at The Hillingdon Hospitals NHS Foundation Trust, stated that the financial regime during 2020/2021 had been slightly unusual and it was anticipated that this would return to relative normality by April 2021.
Concern was expressed in relation to hospital processed and criteria led discharge as there had been some elderly patients whose care packages had been misaligned with their needs. It was suggested that consideration be given to the dissemination of information to those carers and relatives that would be supporting elderly patients out of hospital. Mr Seez advised that the discharge process for elderly patients was a huge logistical exercise. Although feedback on discharge was generally quite good, it was recognised that improvements were required in some areas with regards to vulnerable and frail patients to ensure that their discharge was more joined up. The communication needed to be joined up irrespective of whether it was during the week or at the weekend to ensure that the focus was on planning for discharge.
Members were advised that a communications campaign had been undertaken in Hillingdon in relation to IAPT. Messages about how to deal with low level anxiety and encouraging people to talk had been pushed out through bus shelters, noticeboards and through social media. It was recognised that low level anxiety could escalate if it was not addressed. Consideration would need to be given to how this could be tied into non statutory organisations going into the winter period.
The Hillingdon Hospital NHS Foundation Trust (THH)
Mr Jason Seez, Acting Chief Executive at THH, advised that THH had been working as part of the system which included acute services, primary care, secondary care and community services. He thanked Mr Fisher and the LAS for the input that they had had in improving services at Hillingdon Hospital.
It was noted that there was still some uncertainty about the second wave of COVID-19. About a month previously, there had been approximately 15-18 patients diagnosed with COVID-19. This had risen to 30-35 cases in the last week which, although a notable increase, was not as high as it had risen during the first wave.
Mr Seez noted that the CQC had undertaken an unannounced inspection of Hillingdon Hospital on 4 and 5 August 2020. Since then, action had been taken by the Trust to improve infection prevention and control measures. On 29 and 30 September 2020, the CQC had undertaken a follow up visit alongside the Health and Safety Executive (HSE): the CQC’s interest had been more from a patient perspective and the HSE’s interest had been more from a staff perspective. Key issues had arisen in relation to the development of new staff changing facilities which had been incorporated into the work around the COVID/Non COVID pathway changes in ED/UTC. This work would include changes to the infrastructure at the front end to define COVID and Non-COVID routes.
It was noted that some might ask why significant money was being spent on infrastructure work at Hillingdon Hospital when the building would be torn down in the next three years. The Committee was aware that the changing room work was being funded externally from a ringfenced NHS pot.
The HSE/CQC visit had also resulted in further action being taken in relation to reusable masks with filters. Although it was the responsibility of the individual user to ensure that they checked their filters and valves on a monthly basis, the Trust would complement this with additional corporate tests on the masks over the next six months.
The Committee was mindful that it would usually receive an update on the performance of A&E against the four hour waiting target. Although the target was to see 95% of patients within four hours of attending A&E, the hospital had achieved a figure in the low 80%s. There had been issues with regard to the flow of patients around the hospital which had resulted in THH’s performance being mid-table in London. There had also been staffing issues and a diarrhoea and vomiting episode which had impeded the flow for about a week and affected medical access. An IT issue had also taken down diagnostic capability over a weekend which had impacted on the figures. It was noted that numbers were down on the previous year and that the action being taken with regard to staffing and logistics would help to alleviate this with a month on month performance improvement already seen over the summer period.
Concern was expressed that the failure to reach the four hour waiting target continued year on year. Members had previously raised concerns and had requested (but never received) a copy of the HR staffing strategy about two years ago.
Mr Seez advised that THH had been working with Chelsea and Westminster Hospital (C&W) on improvements with regard to infection prevention and control at Hillingdon Hospital. The Chief Executive at C&W had been working closely with THH to provide support. THH had also been working with Hillingdon Health and Care Partners (HHCP) too to ensure that the Trust worked as part of the system to deliver what patients needed.
With regard to the new hospital development, the strategic outline case had been presented to the Joint Investment Committee at the NHS and been agreed with conditions relating to the detail required in the next stage which would be the submission of the outline business case in the summer of 2021. The full business case would then need to be submitted by the summer of 2022 so that construction could start at the end on 2022. Mr Seez thanked colleagues for the support that they had provided to date.
Members expressed concern that Hillingdon Hospital’s management team had lacked continuity for some time. Mr Seez advised that a new Chief Executive had been appointed (Patricia Wright) and would start at the end of November 2020. The current Chief Nurse would be leaving in January 2021 and the Chief Nurse from C&W would cover this position at THH. Dr Guby Ayida from C&W had also started as the Medical Director at THH. It was noted that the Finance Director post had been vacant for some time and had been covered in the interim whilst recruitment was undertaken. A Director of Nursing had been appointed and Mr Seez advised that he would be staying at the Trust and running the programme for the redevelopment of Hillingdon Hospital.
Disappointment was expressed that there had been such instability amongst senior staff at a time when they were needed to deal with a new hospital build. To date, there were still changes being made to the senior management team and it was queried why so many individuals from C&W were having a say in the future of THH on a part time basis. Member had been keen to see more creative thinking with regard to the new hospital rather than just a like for like replacement in a new building.
The Chairman thanked Mr Seez for his continuing contribution and the stability that he had provided in flag waving for the new hospital in Hillingdon. However, with so many changes to the senior management team at THH, it was difficult for those outside of the organisation to trust them to do what was best for the residents in Hillingdon.
Mr Seez thanked Members for their ongoing perseverance. There had been a wholesale change of management over the last three years and it was recognised that a stable leadership team was needed for five years to be able to get anything done.
Healthwatch Hillingdon (HH)
Mr Dan West, Chief Executive Officer at HH, advised that HH had moved to remote working since March 2020 so there had not been a presence at the Pavilions shopping centre. However, the service had continued by phone, email and social media. There had been a huge increase in the uptake of social media contact.
During this time, mental health concerns had been raised as a key theme and HH had been included in the Hillingdon Health and Care Partners (HHCP) COVID Hub. Mr West thanked Ms Morison for including HH in the Hub as it had informed a lot of the work undertaken by HH and the information that had been sent out.
Concerns had been raised in relation to people going in to hospital and, over the last six months, advice and guidance had been provided accordingly. Young Healthwatch Hillingdon had also continued to work during this period with the Healthfest event being held online.
RESOLVED: That:
- Ms Odlin provide an update on the Cove crisis service at a future meeting;
- Ms Odlin provide an update on the impact of the withdrawal of the Section 75 agreement at a future meeting;
- Ms Odlin provide Members with an update on the impact of the IAPT service and the implications of home working for staff at a future meeting;
- Ms Morison forward information on the uptake of breast screening to the Democratic Services Manager for circulation to the Committee; and
- the presentation be noted.
Supporting documents:
PDF 114 KB