Agenda item

Attending for this Item from Worcestershire Acute Hospitals NHS Trust (WAHT) were:

Matthew Hopkins, Chief Executive

Jackie Edwards, Deputy Chief Nursing Officer (Quality)

The Chairman welcomed the Chief Executive to his first HOSC and in turn the Chief Executive introduced himself by reporting that he had been in post since 14 January 2019 and was looking forward to working with partners to improve the quality of acute health services for the residents of Worcestershire.

By way of presentation, the Committee was reminded that since the last WAHT report on 26 November 2018, there had been no Trust wide Care Quality Commission (CQC) inspection and therefore overall ratings remained unchanged.  However, department reports were available following unannounced CQC visits.  All inspection reports were available on the CQC website -  www.cqc.org.uk

The Trust’s Quality Improvement Strategy (QIS), which was launched in June 2018, and discussed at the November HOSC, was driving improvement through the Divisional, Directorate and Ward Quality Improvement Plans, such as the Patient Safety Plan, the Clinical Effectiveness Plan and the Patient, Carer and Community Engagement Plan.  This was the first time there had been a Trust-wide review and Strategy.

It was reported that engagement had been undertaken to understand what patients thought quality meant, with 99% of respondents feeling that they had ‘good care’, which was defined as being treated with dignity and determining what was wrong, in order to provide a remedy.  In addition, the majority of respondents felt they received ‘safe care’ with visible improvements.  External feedback, from surveys and online resources, was also cited, with positive patient experiences referred to.  These overall positive reactions were not in line with the reported preconceived expectations of the Trust.  Many had reported they were expecting a poor experience of care depending on their destination hospital, and these expectations had generally been framed from negative reports in the local media.

Patient experience was now gathered in real time and, if possible, suggestions for change were implemented.  One example was given, where snacks had been made available, in response to patient feedback.

The Trust acknowledged that in the past, external feedback such as on the NHS website, had not always been responded to in a timely manner.  However, now it was read on a daily basis and actioned accordingly.

Internal monitoring was focussed on quality audits, listening in to handovers, safety walkabouts and experiencing life on the floor; where senior leaders worked alongside front line teams on a weekly basis.  This latter element was now embedded as routine and Leaders and Staff welcomed the approach.

Although there had been no change to the overall Trust CQC Ratings since February 2018, there had been a cultural shift since the introduction of the Trust’s 4ward behaviours change programme, where one of the four pillars was ‘work together, celebrate together’ and recognition had been received for the Meadow Birthing Unit and an award from the Nursing Times. 

A Trust wide accreditation programme (Path to Platinum) had been launched, which would enable wards, departments and theatres to strive for excellence through four levels.  This focused on quality improvement and recognised progress on a monthly basis.

In summary, quality improvement was key and there was a commitment to improve patient experience.  Senior Leaders had responded well and the addition of a Quality Improvement Matron would mean bespoke support was available to all clinical areas.

In the ensuing discussion, the following main points were raised:

·         There was no confirmed date for the next CQC inspection, however, as there had been a request for information, the Trust anticipated that an unannounced inspection would occur in May

·         The Chief Executive was asked to provide further information on his top three priorities, to which he reported:

§  Quality Improvement - by providing a service that patients deserve and the public expects

§  Better Use of Resources - by ensuring the Worcestershire £ was spent appropriately and that waste was eradicated

§  Organisational Change - by managing the workforce to become a successful organisation

·         The Chief Executive also added that he believed that there was no doubt that the Trust being in special measures was a detriment to its reputation, but felt that by having an ongoing open dialogue with the public, partners and media, this could be turned around and sought assistance from HOSC Members to achieve that

·         In response to a query for specific examples of improving quality, it was reported that fractured neck of femur (broken hip) time to surgery performance had improved massively and targets had been met for the second consecutive month.  Worcestershire Acute Hospitals NHS Trust was one of the best performing Trusts in the country for this.  In addition, as more elective surgery had been undertaken at Redditch’s Alexandra Hospital, there had been increased bed capacity at Evesham Community Hospital, which was operated by Worcestershire Health and Care NHS Trust.  A further example was given whereby the number of patients sustaining Grade 3 and 2 hospital acquired pressure ulcers had decreased and there had been no Grade 4 ulcers.  This was part of a national initiative

·         A Member commented that the Path to Platinum accreditation programme suggested that working towards Bronze seemed to indicate current poor performance. It was clarified that the levels were the scheme’s wording and Bronze was not poor.  Progression from Bronze to Platinum was a training path

·         Members were pleased to hear that the Chief Executive had settled in well and was expecting to be in post for some time.  The Trust Board was committed and had a clear strategy to move the Trust out of special measures.  The Chief Executive reported that although improvements were being made, they needed to be embedded; and that would take time – a journey suggested to be 3 to 5 years.  He clarified that patients should see improvements during this time but it would take this long to be confident changes were fully embedded and there was a culture of patient safety

·         In response to a query as to whether the resources were in place to take the Trust out of special measures, the Chief Executive responded by reporting that health funding nationally was a concern.  There was a question as to whether the funding allocated to the Worcestershire Clinical Commissioning Groups truly represented the needs of the population and then a further question about whether the level of CCG funding allocated to the Acute Trust was appropriate.  Members were reminded of the statistic that in terms of activity over the Winter period, the Trust was predicted to be 104 beds short and this analysis had been accepted by both commissioners and providers. Work was being carried out to address this shortfall.  However, CCG funding was based on activity not extra bed capacity and a significant challenge remained about staffing

·         In addition, the NHS Long Term Plan, which launched in January 2019, was vague in relation to ongoing Capital funding.  This was a concern at present, however, the Trust was pleased with the Capital funding already allocated for the Link Bridge and other works.  The Trust understood that the additional funding for the other works was potentially allocated, but further business cases were needed and would include an extra 150 car parking spaces, theatre refurbishment and other elements as originally planned

·         Potential additional capital projects included an elective care centre to support maximising the use of the Alexandra Hospital site, endoscopy and an ambulatory care facility to enable GP’s to refer directly rather than to A&E.  In future, capital allocation for such projects would be by STP footprint

·         The Workforce was a further resource, which required stability.  A plan to reduce vacancy rates and recruit appropriate staff across the organisation was being developed.  Spend on Agency Staff was significantly more than expected and overall in the region of £21m, around £4m more than anticipated.  The Trust had set some efficiency targets, however, it was also reported that market forces led to fees increasing nationally which was not in the best interests of any Trust.  Hourly rates were inflated and Agency Staff potentially worked side by side with permanent colleagues for as much as three times more per hour.  The Trust had committed to looking at alternative approaches, such as using their own Staff or enticing Agency Staff to contracts

·         In relation to capacity, it was reported that extra bed capacity was beginning to make a difference.  The Chief Executive reported that a mind change was required across the Trust and length of stay needed to reduce, with some patients reported to stay up to a week longer than clinically necessary.  It was stated that a proper discharge plan was required to make best use of bed capacity and he acknowledged that there was lots of room for improvement

·         Ambulance handover times had improved and more efficient ways of working would make a difference.  The Chief Executive had recently worked a night shift with an ambulance crew and commented that not all A&E visits were necessary, suggesting that the 111 service could triage more appropriately

·         When asked whether patients were coming to harm because of the pressures in A&E, it was reported that nationally it was known that mortality rates increase if there was a delay in A&E.  There was a dedicated Corridor Care Nurse at Worcestershire Royal and procedures were in place to review and monitor all patients.  Care, comfort and dignity continued to be paramount and during the January 2019 unannounced CQC inspection, this process was commended

·         One Member sought clarity over reports that Kidderminster Hospital would close wards at the weekend, to be informed that no decision had been made, but work was being undertaken to plot capacity with demand.  The Chief Executive was aware of the sensitivities locally around these reports but reiterated the need to be efficient and provide best value for money

·         Delivery against some key performance targets was not being met, with capacity not matching expected demand.  In relation to Cancer Services, the Chief Executive was confident that the 62 day standard to treat patients and also the diagnostics (MRI) standard would be met by September 2019.  For non-urgent treatments, the 18 week referral to treatment standard had been in decline.  The Trust had predicted that it would require a further £7-8m to tackle the backlog of patients waiting for longer than 18 weeks and was in dialogue with the CCGs to determine whether any additional funding was available for this

·         One Member commented that if appropriate funding was not available, it seemed unfair that the Trust was penalised for not achieving targets set.  The Chief Executive stated he was merely presenting facts and was being transparent in his approach to reporting

·         The Committee noted that the Sustainability and Transformation Partnership (STP) was considering centralising a hyper acute Stroke Service across the STP footprint of Herefordshire and Worcestershire, with the proposed centre being at the Worcestershire Royal site.  It was noted that the Committee was due to look at stroke services at its meeting in June

·         In response to a query about additional support, it was reported that NHS Midlands Team was providing additional support and guidance, including training.  Co-ordinating support in a helpful way was a challenge

·         Members queried reports that the new Link Bridge was on a gradient, to be informed that it was and motorised bed pushers were now used resulting in improved patient comfort.

The HOSC Chairman invited Simon Adams, the Managing Director of Healthwatch Worcestershire to comment on the discussion, with the following points being made:

·         Healthwatch was also concerned about the fair funding of health services in Worcestershire

·         In terms of performance, the West Midlands had the largest increase in cancer patients in the country, so it was not surprising that referral and treatment standards were not being met.  However, the Trust was the only one in the West Midlands meeting the 14 day wait target on this.

In response, it was reported that the NHS was under tremendous pressure nationally and Cancer services in particular were reaching a tipping point between growth and demand. Urology was cited as a particular challenge due to the volume of demand and the way in which a multi-disciplinary team managed processes.

The HOSC Chairman thanked all present for a very informative and refreshing discussion.  The Committee recognised the challenges ahead and looked forward to a progress update in due course.