Agenda item

The Chairman welcomed those present to the meeting.  The importance of having a full suite of key performance indicators (KPIs) was recognised and, as there was a vast range of information available, it was agreed that Members would request the specific information they required prior to health partners attending meetings. 

 

Hillingdon Health and Care Partners (HHCP) / North West London Integrated Care System (NWL ICS)

Mr Keith Spencer, Managing Director of HHCP, advised that a range of KPIs had been included on page 17 of the agenda which provided a comparison to other London boroughs.  He noted that the focus of HHCP's work in 2022/2023 had been on four main areas with a goal of delivering more care closer to home:

1.    Embedding population health management and addressing areas of inequality;

2.    Ensuring best use of resources to address the Hillingdon Health Place Based financial deficit;

3.    Developing and progressing the clinical models and activity shifts for the new hospital development programme; and

4.    Delivering the three main priorities in the place based transformation programme:

a.    Integrated neighbourhood development;

b.    Reactive care; and

c.    End of life care.

 

Ms Sue Jeffers, Joint Lead Borough Director at NWL ICS, advised that there had been more face-to-face GP appointments in 2022 (690,900) in comparison to 2021 (587,811), which was an increase of 17.4%.  There had been a 6.4% increase in the total number of appointments attended in 2022 (1,135,045) compared to 2021 (1,066,363).  Members noted that, even though there had been a reported 6.4% increase, this had been difficult to reconcile when residents were still struggling to get an appointment.  It was queried how many people presenting at Accident and Emergency (A&E) would have gone to their GP if there had been appointments available.  Ms Jeffers advised that there continued to be an increase in demand which had proved to be a challenge. 

 

Ms Jeffers advised that, pre-Covid, approximately 5% of appointments had been virtual.  During the pandemic, 100% of appointments had been virtual and now approximately 35% of appointments were virtual.  As some patients were not comfortable using technology, and because some cohorts of patients had to be seen face-to-face, it was essential that a hybrid approach was taken to meet the needs of patients and manage the day-to-day demand for services. 

 

Work was underway to introduce a cloud-based telephony system which would help to reduce the bottleneck of telephone calls received by GPs every morning where patients were trying to book an appointment.  Three primary care access hubs were also being set up in the north, centre and south of the Borough to manage same day urgent demand and undertake diagnostic tests to resolve issues in one place rather than referring on to another team elsewhere.  The first hub was likely to go live in July 2023 with the second opening at the beginning of October 2023.  It was agreed that Mr Spencer would provide an update on the effectiveness of these hubs in meeting the demand for GP appointments at the Committee's meeting on 21 November 2023. 

 

Ms Jeffers advised that residents that were unable to get an appointment with their GP could phone NHS 111 and ask them to book an appointment for them.  A number of GP appointments were allocated to NHS 111 each day which they could directly book patients into (this was monitored by NWL ICS).  Members noted that this action did not always result in residents getting a GP appointment either and that some residents were unable to register with a GP at all.  Ms Jeffers advised that all GP practices in Hillingdon operated open lists so, if there were any issues, Members should let her know and she would be able to facilitate registration at a practice. 

 

Ms Lisa Taylor, Managing Director at Healthwatch Hillingdon (HH), advised that GP access was a significant issue in Hillingdon.  However, it appeared that this issue was often largely due to poor communications and the need to better manage patients' expectations.  Members noted that there were also issues with forward planning where residents were not able to book an appointment for three days' time.  Ms Jeffers advised that this linked to performance and systems needed to be put in place to enable practices to plan out appointments. 

 

A national patient experience survey was undertaken annually and NWL ICB was able to break the data down to a Borough level – Ms Jeffers would pass this information onto the Committee.  In addition, Patient Participation Groups (PPGs) had also been created in practices.  Some PPGs were more effective than others and some struggled to get patients to engage. 

 

Concern was expressed that residents in Heathrow Villages had not had GP services provided locally for a very long time and that this lack of coverage was unacceptable.  Mr Spencer advised that partners had been out and working with the residents in Heathrow Villages to come up with solutions together.  Members asked that Mr Spencer return to a future meeting to update them on what the plan of action was to move this forward (once it had been agreed) and timescales for when this action would be implemented. 

 

Ms Patricia Wright, Chief Executive at The Hillingdon Hospitals NHS Foundation Trust (THH), advised that the Urgent Treatment Centre (UTC) had been working with GPs to redirect patients (where possible) back to practices.  It was noted that around 20% of all ED attendances could be redirected to primary care following the introduction of initiatives such as the hubs but there had been an increase in the expectations of residents to have immediate access to care. 

 

Ms Jeffers advised that Hillingdon continued to be one of the highest performers in NWL in relation to vaccination uptake and had one of the lowest admission rates for people aged 65+ with severe frailty.  Hillingdon was also achieving the best performance across London for the highest proportion of hospital discharges by 5pm each day as well as or the lowest overall period of stay for patients needing to stay longer than a week. 

 

Hillingdon had improved its performance for the percentage of people with a serious mental illness receiving a physical health check from 66% to 70.4% against a NWL target of 60%.  81% of those aged over 40 with a learning disability had received an annual physical health check.

 

Key areas for future work included:

·         Reducing avoidable Emergency Department (ED) attendances;

·         Improving hospital discharges;

·         Increasing the uptake of bowel cancer screening – it was anticipated that an increase would be achieved with initiatives such as the development of community link workers who would contact patients who had not attended a bowel cancer screening appointment;

·         Improving the accuracy of the recording of dementia data as well as improving waiting times for assessment and associated diagnostics; and

·         Addressing inequalities including hypertension – hypertension was the biggest cause of ill health in Hillingdon so blood pressure (BP) monitors would be installed in libraries and other community areas to enable residents to check their own BP.  Publicity for this initiative would need to be undertaken and Ms Jeffers would forward further information about the initiative to the Democratic Services Manager for circulation to Members of the Committee. 

 

Members queried how the draft future state operating model would work.  Mr Spencer advised that, although the model looked complicated, it was much simpler that the current operating model and had been developed with partners so had significant support.  He reminded Members that around 5k residents used 70% of the health resources in Hillingdon.  Neighbourhoods would form the building blocks for delivering care to residents closer to home and help to deliver more preventative initiatives. 

 

The NHS operated a referral system where patients were passed from one team to another.  The neighbourhoods model meant that staff from different organisations and disciplines were brought together in one place to work around the patients' needs and make a difference.  It was anticipated that the first 9 priorities would be implemented by September 2023 so Mr Spencer would be able to attend a subsequent Select Committee meeting to provide Members with an update on the impact that the new model had made. 

 

In terms of the performance of the 42 GP practices in Hillingdon, Members were advised that the CQC inspections had ceased during the pandemic and would be starting up again soon.  The Hillingdon primary care team was also beginning to set up a programme of visits again.  Ms Jeffers advised that timings would need to be looked at in terms of reporting back to the Committee on progress. 

 

A review of community eye services was currently underway with an associated consultation.  A survey had been distributed to gather information to feed into the future deliver proposals.  It was suggested that this could be a possible future report to the Committee. 

 

Ms Jeffers advised that, on 1 April 2023, NHS England delegated commissioning responsibilities for dentistry, ophthalmology and pharmacies to NWL ICS.  Members were particularly interested in how dental provisions coming under NWL control would work.It was agreed that a further report on the provision of these services be brought to the Committee's meeting in June or July 2023. 

 

The Hillingdon Hospitals NHS Foundation Trust (THH)

Ms Patricia Wright, Chief Executive at THH, advised that the Trust had a huge range of KPIs which were available on their website and which were updated on a monthly basis (https://thh.nhs.uk/how-are-we-performing).  The Trust's performance was also reported to the Board in common and compared Hillingdon's performance with that of the other NWL acute providers (Hillingdon was comparing favourably). 

 

Ms Wright acknowledged that the Committee had previously had serious concerns about the Trust's performance, both in terms of its finances and quality.  During 2022/2023, there had been a focus on improving performance and becoming a more sustainable organisation through work such as the development of a new five year strategy that would make the Trust affordable and provide high quality services. 

 

Now that the world was moving out of Covid, it would be important to return to pre-pandemic performance levels.  A CQC inspection had been undertaken in 2018 and performance improvements had been achieved in 2019/2020.  The Trust's performance had now broadly returned to its pre-pandemic levels and significant progress had been made against elective targets.  Urgent and emergency care performance was below the national target but was in line with the London average and cancer performance was variable but was improving. 

 

A gap analysis of the CQC key lines of enquiry had been undertaken in the spring / summer of 2022.  A peer review had also provided the Trust with valuable feedback on progress and had seen improvements.  In November 2022, the CQC undertook an unannounced visit and the Trust had received positive feedback about the progress made since the inspection report.  However, the Trust had received a compliance order in relation to sharing and disseminating earning across the organisation. 

 

THH had recently been successful in recruiting new volunteers but there was further work that could be done in partnership with the Council.  With regard to staff, Ms Wright noted that the staff needed to be engaged.  The results of the most recent staff survey had been in line with those of the last few years but it was recognised that this needed to improve.  Bank and agency spend was back in line with the 2019/202 position and vacancy rates had decreased for qualified nurses.  To recognise good performance, the Trust had reintroduced the staff recognition and celebratory events and an open day would be held at Mount Vernon Hospital on 8 July 2023 where the staff could be celebrated. 

 

Targets to address the elective backlog had recently been challenged by the strikes but effort had been made to eliminate the 78 week waits.  The target for 95% of A&E patients to be seen within four hours had been revised for 2023/2024 and reduced to 76% (although the Trust was still aiming higher than this) – performance tended to vary on a day-to-day basis. 

 

Ms Wright advised that THH had taken over management of the Urgent Treatment Centre (UTC) in February 2023 and had since seen improvements in its performance.  There had been reductions in ambulance hand over times and waits. 

 

With regard to cancer targets, Members were advised that improving performance had been challenging.  Ms Wright noted that THH did not have control over the complete cancer pathway but had still managed to significantly reduce the waiting times. 

 

THH had put three strategic programmes in place:

1.    Digital – the Trust was on track to go live with the NWL acute electronic patient records system in November 2023;

2.    Redevelopment – there had been lots of issues at a national level that needed to be resolved; and

3.    Sustainability – the Trust had won a number of awards in relation to sustainability. 

 

Insofar as out of hours and weekend hospital discharges were concerned, Ms Wright advised that the Trust had put measures in place to better monitor this performance and returns were now provided on a weekly basis.  Performance for discharges prior to 5pm continued to be good but there was still room for improvement. 

 

Concern was expressed that there had been some older people admitted to hospital that had also been suffering with chronic loneliness.  These individuals had welcomed the companionship that they had received during their hospital stay.  Ms Wright advised that the Trust had a very positive relationship with social care in Hillingdon and that she would investigate the possibility of better signposting patients to support such as befriending services.  She stated that there were currently no mixed wards at Hillingdon Hospital (although it was permissible to have mixed assessment areas). 

 

With regard to maintaining the structure of Hillingdon Hospital, Ms Wright advised that fire safety had been a concern.  A Fire Improvement Notice had been put in place but a lot of health and safety work had been undertaken to address the issues raised and the Trust was now waiting for the notice to be taken off.  THH had an annual capital budget and a maintenance programme in place but it was always a balancing act.  The decant and enable monies associated with the redevelopment work had allowed the Trust to refurbish or build new temporary areas as it moved through the development process.  Ms Wright advised that she would be happy to arrange a site visit for Councillors to see the new temporary state of the art wards. 

 

Members asked about what progress had been made by the NWL Provider Collaborative with the orthopaedic inpatient surgery proposals.  Ms Wright noted that there had been a national move towards providing specialist elective centres, especially for high volume services.  Elective orthopaedic surgery would be moving to Central Middlesex Hospital but investigations were still ongoing in relation to the transport options that needed to be available for residents in boroughs such as Hillingdon where travel times would be significantly increased.  The majority of residents' care would be undertaken in Hillingdon but they would need to attend Central Middlesex Hospital for their surgery and a short inpatient stay before either going home of becoming an inpatient in Hillingdon Hospital.  This proposal would now move at pace, although it would be a gradual transition over the course of this financial year. 

 

Royal Brompton and Harefield Hospitals (RBH)

Ms Derval Russell, Harefield Hospital Site Director at Guy's and St Thomas' NHS Foundation Trust, advised that Harefield Hospital had experienced a number of challenges in relation to elective surgery and recovery.  After Covid, significant effort had been made to reduce the elective waiting lists.  However, the patient split had flipped from two thirds elective and one third emergency / non-elective to one third elective and two thirds emergency / non-elective.  This meant that progress in reducing the elective backlog was somewhat limited, especially when there were also challenges around increasing the workforce capacity. 

 

Ms Russell advised that there were a lot of ethical considerations when recruiting overseas, for example, to ensure that the country of origin was not left with a shortage themselves.  Hospitals often worked with recruitment agencies who targeted overseas countries and undertook a lot of the administration.  There was an expectation that successful recruits would usually stay and work in the UK for at least two years.  Members were advised that there had been a successful overseas recruitment drive in 2022 but that it took a while to get these new members of staff sufficiently trained and inducted.  Cardiac physiologists were needed for almost all procedures at Harefield Hospital but there was currently a national shortage.  RBH had been working with Brunel University to look at addressing this and plan for the future.  There had also previously been a steady supply of overseas doctors for critical care but they had recently stopped coming.  Ms Russell advised that the Hospital did not have a retention issue - it had challenges with recruitment as Harefield was comparatively remote for a London hospital.

 

Members were advised that staff were currently working on setting up for a new cohort of apprentices who would be expected to start in September 2023 or spring 2024.  These apprentices would undertake a variety of placements along the way during the course which would be provided by Middlesex University.  This had proved to be a popular way to recruit new members of staff. 

 

Harefield Hospital had met the target to eliminate all 78 week waiting elective patients by 1 April 2023.  The Hospital was now looking to clear those who had been waiting 52 weeks and was confident that the target would be met as there were not that many of them. 

 

Ms Russell acknowledged that, during their wait, it was possible that the status of cardiac patients might deteriorate.  To support these patients, a digital platform had been developed which enabled the hospital and patient to monitor their symptoms during their wait (those patients who were not able to use the technology received regular 'risk of harm' telephone calls).  This had helped to manage the risks. 

 

Ms Russell advised that the capital available to hospitals had been significantly reduced in recent times (regular annual condition surveys were undertaken as part of the backlog maintenance programme to prioritise spend).  As such, a significant amount of transformative and innovative work had been undertaken in relation to critical care pathways.  To enable cardiac patients to be moved through the pathway efficiently, the transformation work needed to address the whole system (if appropriate, some patients were able to be admitted on the morning of their surgery rather that the night before).  There had also been a move towards increasing the research contribution made at Harefield Hospital. 

 

Royal Brompton and Harefield NHS Foundation Trust had merged with Guy's and St Thomas' NHS Foundation Trust (GST).  GST had been putting together a masterplan for the development of Harefield site.  Rehabilitation facilities had been increased but there were currently issues in relation to the electricity supply to the site (as well as to the village itself) and the Trust had been working with Southern Electric to resolve the issues. 

 

Central and North West London NHS Foundation Trust (CNWL)

Dr Paul Hopper, Divisional Medical Director at CNWL, advised that the report included on the agenda covered a range of adult services development and children's services development.  Action was being taken to recruit for mental health support team staff for schools so that this could be rolled out across Hillingdon.  Additional Roles Reimbursement Scheme (ARRS) posts were being developed with each of the Primary Care Networks (PCNs) in Hillingdon. 

 

Dr Hopper advised that, over the last twelve months, the performance of the core CAMHS service had been quite impressive, meeting its 18 week performance target 95% of the time.  The number of children and young people waiting had reduced by 60%. 

 

With regard to children's physical health services, Members were advised that face-to-face services such as speech and language were now back up and running and meeting their performance targets. 

 

In adult mental health services, there had been a focus on flow and the management of acute demand.  For example, a Mental Health Crisis Assessment Service (MHCAS) had been opened to take people in for a period of assessment rather than them waiting in A&E for assessment.  A specialist rehabilitation triage unit had also opened in the autumn helping acute mental health wards with patients that had been there for a long period of time and provided them with a period of intensive rehabilitation support. 

 

The Retreat (crisis house) had been open since summer 2022 and provided an alternative to a hospital setting (Members had been provided with some case studies).  As The Retreat was relatively new, it was not yet as well used as it could be.  Meetings had been held with the provider to look at improving its use and, as a result, the restrictions had been relaxed and the potential cohort of those who could access had been widened (whilst ensuring that the relevant safeguards were in place).  As a result of their stay, many service users had been able to go home afterwards rather than be admitted to hospital. 

 

Dr Hopper advised that The Retreat was unlikely to be successful in isolation.  The case studies that Members had been provided with illustrated enduring challenges that had been faced by the service users.  However, measures needed to be put in place to encourage longer term changes to prevent these individuals from coming back to The Retreat multiple times. 

 

Members queried whether consideration had been given to using The Retreat to redirect young people who had presented at A&E with mental health issues and who needed a calm space.  Dr Hopper advised that young people aged 16-17 should not be placed with adults and that, if they needed the inpatient specialist CAMHS service, a place would be found for them.  However, it was not always that clear cut as they might need an appropriate place to live in the community or access to the urgent care outreach service which provided intensive support. 

 

The opening hours of the Cove café had been extended and the café was now open seven days each week.  The number of people using the café was good but it was suggested that the venue was not in the best place and consideration needed to be given to moving to another location. 

 

Other initiatives included the discharge liaison project which placed community nurses on Hillingdon Hospital wards to identify individuals who could be moved off the ward and back into the community. 

 

Members noted that, with regard to addictions, Hillingdon had previously been an outlier for drug and alcohol admissions.  Dr Hopper would establish what the current situation was and forward this information on to the Democratic Services Manager for circulation to the Committee. 

 

The London Ambulance Services NHS Trust (LAS)

Mr Chris Reed, Hillingdon Group Manager at LAS, advised that teams-based working had been undertaken in Hillingdon where crews went out on rotas.  Demand modelling was now being undertaken and it was hoped that this would be in place by September 2023.  This new approach would increase support for clinicians as there would be a manager available on each rota and reduce the response times. 

 

Mr Reed advised that the Category 1 response times had been a challenge over the last year but were now thought to be at an acceptable level.  The Hillingdon Group also continued to review clinical quality, champion Alternative Care Pathways (a Frailty Assessment Unit was being developed at Hillingdon Hospital as part of this initiative) and reduce conveyances to A&E.  By further increasing the clinical development of LAS staff, the Trust was aiming to reduce conveyances to less than 50% (it was thought that teams-based working would also help with this). 

 

Work had been undertaken over the last year in partnership with Hillingdon Hospital to reduce hospital delays.  In April 2022, the average handover time to Hillingdon Hospital was 22.5 minutes.  This had reduced to 17.8 minutes in April 2023 (which was lower than the LAS average of 25.3 minutes). 

 

Mr Clinton Beale, Stakeholder Engagement Manager at LAS, believed that that the systems were in place to get patients to the right place as quickly as possible.  Access to electronic patient records improved efficiency and also helped clinician to clinician conversations across the board.  Universal care plans and care records could now be accessed for each patient on scene so patients were not being conveyanced if it was going to be detrimental to their health. 

 

A Trust-wide initiative had been introduced to use more cars and, as such, 42 electric fast response vehicles had been added to the fleet.  Hybrid ambulances were also in the process of being added to the fleet and electric ambulances were being tested.  However, consideration would need to be given to the amount of time that electric ambulances would be out of action whilst they were recharging and how much of a logistical challenge this would cause.  A very successful cycle response unit continued to operate from Heathrow airport. 

 

Although staff sickness rates had been a challenge over the last few years, the number of staff on long term sick had reduced month-on-month over the last year.  There continued to be spikes in short term sickness absences but this had generally not been caused by Covid as the staff had been issued with PPE. 

 

It was recognised that LAS staff did a very challenging job and that they never received any feedback on whether or not they had got it right.  Once patients were dropped off, the outcomes for those patients remained unknown to the LAS staff. 

 

The Trust worked with EDs, emergency services, primary and secondary care at a pan-London level with ICSs.  It looked to develop services that were provided in other ICS areas. 

 

Healthwatch Hillingdon (HH)

Ms Lisa Taylor, Managing Director at HH, advised that HH had been commissioned by the local authority and undertook work to understand the needs of local residents.  To enable this to happen, a representative from HH sat on most of the partnership bodies in Hillingdon and was therefore part of the local conversations. 

 

HH was able to make recommendations to the Care Quality Commission (CQC) but had not used its statutory viewing powers since the pandemic had started.  Ms Taylor advised that the organisation was able to signpost patients who wanted to make a complaint and ran outreach programmes.  HH had a Board of Trustees and a cohort of volunteers and had developed Young Healthwatch Hillingdon for those aged 11-25. 

 

Young Healthwatch Hillingdon had undertaken a review of the sexual health services available to young people in the Borough.  This work had sparked a review of the services available across the whole of NWL. 

 

Members were advised that HH had worked on the evaluation of PATCHS which had been procured to enable online GP consultations.  HH continued to be involved as part of the roll out of the system. 

 

HH had continued to support HHCP with population health management workstreams.  This work had looked at preventing falls and frailty and end of life care. 

 

Ms Taylor advised that every local Healthwatch had been invited to provide input to shape the LAS organisational strategy for 2023-2028.  To collect the thoughts of local residents, HH had developed and published an online survey (which had received over 450 responses) and carried out 121 interviews with service users.  The feedback received had been largely very positive and had resulted in a number of recommendations being included in a report drafted by HH and presented to the LAS.  Ms Taylor advised that she was now waiting for confirmation of the next steps and consent to publish the full report in 2023. 

 

Amongst other things, HH had been working with HHCP to improve awareness of (and access to) community pharmacy services in wards identified as high health inequalities and low vaccine uptake rates.  A review had also been undertaken of GP websites and the process of how to complain.  Inconsistencies had been identified across the 43 practices with incorrect information and a full report would be produced and shared with providers for response prior to publication. 

 

Ms Taylor noted that there had been a significant number of residents contacting HH in relation to dental services.  Now that dental services were being commissioned at a NWL level, this would be an important step in influencing the future commissioning of dental services in the Borough. 

 

Insofar as HH volunteers were concerned, it was noted that there had been a decline in numbers.  It was likely that this had been partly caused by the cost of living crisis with individuals having to take paid employment rather than volunteering.  However, there had been some interest recently from medical students.  There was also a need for more Board members but it was recognised that HH was not alone in facing these challenges. 

 

RESOLVED:  That:

1.    Mr Spencer provide an update on the effectiveness of the primary care access hubs in meeting the demand for GP appointments at the Committee's meeting on 21 November 2023;

2.    Ms Jeffers pass Borough level information on to the Committee from the national patient experience survey undertaken annually;

3.    Mr Spencer return to a future meeting to update the Committee the plan of action to move forward with providing the Heathrow Villages with a GP and the timescales for when this action would be implemented;

4.    Ms Jeffers forward further information about the hypertension initiative to the Democratic Services Manager for circulation to Members of the Committee;

5.    Mr Spencer attend a future meeting to provide Members with an update on the impact that the new neighbourhoods model had made;

6.    Ms Jeffers provide a report on the delegated commissioning responsibilities for dentistry, ophthalmology and pharmacies to the Committee's meeting in June or July 2023;

7.    Dr Hopper establish the current situation in relation to drugs and alcohol and forward this information on to the Democratic Services Manager for circulation to the Committee; and  

8.    the presentations be noted.