Agenda item

The Chairman invited the Democratic Governance and Scrutiny Manager to outline the purpose and format of the meeting; namely that:

 

·         the purpose of the meeting was to better understand the reasons for poor performance of Worcestershire Acute Hospitals NHS Trust, in particular but not exclusively, in Accident and Emergency (A&E); and

·         to better understand the impact on, and roles of, commissioners and health and social care providers in the County.

 

Representatives from all Worcestershire health and social care partners had been invited to the meeting and the Committee heardfrom each organisation in turn, starting and ending with Representatives from Worcestershire Acute Hospitals NHS Trust.

 

Worcestershire Acute Hospitals NHS Trust (WAHT)

In Attendance:

Matthew Hopkins, Chief Executive

Mike Hallissey, Chief Medical Officer

Vicky Morris, Chief Nursing Officer

 

The Care Quality Commission (CQC) had, at its last unannounced inspection in December 2019, served a Section 31 notice on the Emergency Department at the Worcestershire Royal Hospital, Worcester and the Emergency Department at the Alexandra Hospital, Redditch.  This level of notice was one of the highest the CQC, as regulator, could serve and had been a result of poor performance.  As a consequence, immediate actions were required to improve elements, such as waiting times, ambulance handovers, privacy and dignity.  There had also been a surge of paediatric attendances in November 2019 and safety concerns had also been raised.

 

When the CQC had carried out their inspections in May 2019 (report published September 2019), the procedures and practices were the same as in December 2019.   

 

In the ensuing discussion, the following points were made:

 

·         When asked whether standards had altered between the May and December 2019 Inspections, it was clarified that the standard operating procedure was the same

·         Staffing levels were a concern to the CQC, reflected in references to care in the corridor and consultant cover.  The lack of a permanent presence of paediatric nurse expertise in the Emergency Department had been highlighted during the inspection visit and the Chief Executive explained that this had been addressed immediately, in line with the Section 31 actions

·         Likewise, the lack of space and the use of space was highlighted.  In response to a Member question, WAHT acknowledged that capacity continued to be a challenge, especially when the Worcestershire Royal Hospital had seen an 8% increase in attendances year on year since being built in 2002.  The Chief Executive, with the support of local colleagues and MPs, had written to the Secretary of State for Health and Social Care seeking capital funding to expand the Emergency Departments at both sites; in the meantime, a ‘sticking plaster’ approach was being taken

·         The Trust was near to requiring a dedicated Emergency Department for paediatric patients

·         In comparison to other regional and national Acute Trusts, WAHT was not alone in receiving Section 31 notices from CQC

·         An indicative £40m Capital funding bid had been made, to include the expansion of Emergency Departments on both acute hospital sites, increasing the size of both the Medical Assessment Unit and the Ambulatory Care Unit and building a dedicated Paediatric Emergency Department, all in Worcester.  A three-storey extension was envisaged, although ground space was at a premium.  Further acute stroke beds were also required and work on this was already underway.  County MPs were supportive of the need to futureproof a set of County hospitals

·         From existing Capital funding, it was planned to refurbish 6 operating theatres at the Alexandra Hospital.  A major focus for the Trust was to achieve operations on time

·         Members were reminded of a 2018 WAHT Report which had suggested that there was a shortfall of 110 acute beds in the County.  The gap was narrowing, with 33 beds opened recently.  By the end of May, a total of 107 beds would be open

·         WAHT needed to look at innovative ways of caring for patients, in collaboration with Worcestershire Health and Care NHS Trust in particular, about the use and role of community hospitals, which would hopefully improve patient flow

·         To clarify a point from a previous meeting, any digital improvements may well need to be made from revenue budgets, rather than capital, and £22m continued to be the figure required for this transformational work, including infrastructure.  If it could be from capital investment, it would reduce the overall deficit.  A new Digital Officer had been employed to drive this improvement

·         In response to a specific question about expanding the current A&E Department, it was suggested that in the short-term, adjacent activities could be displaced, however this was not a long term solution.  The Alexandra Hospital had successfully acquired some additional space by relocating the Out of Hours service

·         Patient flow was of concern and the need to safely discharge patients from wards was a priority to stop a bottleneck in A&E; the availability of social care packages was referred to in relation to this

·         An Onward Care Team had been established and had been operating for 10 days.  It was made up of staff from across the health and social care sector and its role was to move patients through the acute system either to home or a place which patients called home.  It was hoped that having close contact with patients and Ward Staff would lead to better outcomes

·         Recruitment was always a challenge and agency staff were heavily relied upon, at significant cost.  However, the Trust reported a reduction to a 9.25% vacancy rate in January 2020.  An international nursing recruitment campaign had also been successful.  To retain nursing staff, flexible working options were considered, as well as creating positions involving increased levels of responsibility

·         Leaders from across the health economy were working with the University of Worcester.  It was in their business plan to establish a Medical School, to complement their current work and provide a valuable local resource of health professionals for the County

·         When asked what key elements were required to drive improvement, the Chief Executive was clear:

Ø  the requirement to embed practices that had been put in place

Ø  to look at best practice from other acute trusts and only admit people that required an acute setting

Ø  have a system wide approach to change mindsets, to challenge ‘unwell’ and promote prevention services to all Worcestershire’s residents.   

 

Worcestershire County Council (the Council) 

In attendance:

Kathryn Cobain, Interim Director of Public Health

Elaine Carolan, Interim Strategic Director for People

 

The Chairman reminded Members that at the last meeting, when discussing the WAHT Clinical Strategy, it was noted that some of the information was not consistent.  By way of update, Council Officers were now working with WAHT colleagues to work through some of the discrepancies.

 

The Interim Directors talked through the work of the Council and the links with other health partners.  In summary:

 

·         The amount of Public Health Ring Fenced Grant (PHRFG) was still not confirmed for 2020/21

·         A new Health and Well-being Board (HWB) Strategy was required by April 2021

·         It was encouraging that the HWB had recently revised its Terms of Reference and membership now included representation from both WAHT and Worcestershire Health and Care NHS Trust

·         The HWB would monitor areas, such as mortality (a nationally defined measure) and included both the hospital stay and the following 30 days.  In Worcestershire, the WAHT figures were higher than national figures, but underneath the confidence level, with the statistics changing on a daily basis.  It was noted that in Herefordshire there was a system wide approach to reduce mortality and Worcestershire could learn from their practice, however, it was important to remember that patients requiring acute hospital services were generally very poorly

·         Public Health Officers would work more closely with Acute colleagues to further understand the data

·         Members learned that the delivery of outpatient appointments was being investigated across the whole health system and could include alternative approaches, such as patients not attending an acute setting for follow up or appointments taking place digitally

·         The Onward Care Team was seen as a positive contribution to the improvement journey.  A pilot project in Redditch had reduced length of stay from 8 days to 5 days and improved patient flow.  However, on occasion there had been cases of arranging discharge to find that the patient was not medically fit to leave hospital

·         The Council had a proven track record of keeping residents living independently for as long as possible and the average age of someone starting to reside in a Worcestershire Care Home was 83.  However, the number of frail elderly in the County was rising, many with complex health needs

·         Discharge from hospital was sometimes a challenge due to non-medical factors, such as patient or family choice, especially in finding available Care Home placements.  In Worcestershire, 80% of residents were self-funders, therefore families often wished to wait for a preferred Home to become available, adding to delays

·         This was the case over the Christmas period, when the Council had block booked 10 Care Home beds, yet only 2 or 3 had been used

·         HOSC Members agreed with Directors that there was much work to be done to manage the expectations of residents, patients and families in sometimes difficult circumstances

·         Those people nearing end of life were always prioritised, however, funding arrangements between partners was complicated

·         The Directors stressed that regardless of difficulties it was vital to remember that the person was at the centre of any communication

·         When asked what improvements could be made, the Directors suggested:

Ø  The need to have a wider conversation about Home being best and how to support residents in that drive, including support, housing and care needs

Ø  That although Community Hospitals were a valuable resource, there were a lot of community beds in the system and therefore people became often too comfortable rather than considering ‘home first’

Ø  That It was vital that all partners across the health and social care system worked together to ensure a commitment to Worcestershire residents.

 

Worcestershire Health and Care NHS Trust (WHCT)

In attendance:

Matthew Hall, Chief Operating Officer

Rob Cunningham, Associate Director Integrated Community Services

 

The HOSC Chairman invited the Vice-Chairman, Mrs F Smith, to lead on the following discussion.

 

Further detail was given on the Onward Care Team, which had around 35 employees based across both acute hospitals.  The Team’s purpose was to have regular contact with the Wards, Multidisciplinary Teams (MDTs), patients and relatives to ensure there was no delay in discharge.

 

Good conversations were had daily and there was proactive forward planning for care after an acute hospital stay, whether back at home (or a place called home), or an alternative setting.

 

Worcestershire generally had more complex discharges than elsewhere in the Country and around 45% of discharges were to a Community Hospital.  Nationally, this figure was around 22%.

 

A funding bid was awarded to assist with winter pressures, specifically around Pathway 1 (discharge home to assess), yet there continued to be difficulties in accessing services such as occupational therapy, physiotherapy and packages of care.

 

The Neighbourhood Team model, where multi-agency teams were based in localities was proving useful in admission avoidance.  There were 13 Teams covering the 11 Primary Care Networks in the County.  The teams worked proactively with primary care to support the older frail population and those with multiple long-term conditions.  The aim of the teams was to prevent admission to hospital and if there, to be a responsive service facilitating step down care.

 

The following main points were made:

 

·         In response to a query as to why Community Hospitals were not more widely used, it was reported that the Trust was proud of its offer, especially their more specialist rehabilitation role.  However, they were used for general admissions more frequently than in comparator Trusts.  Discussions had taken place as to how the Trust could assist WAHT and the wider system and longer term changes could be foreseen, potentially around shorter stays

·         ‘Step Up’ and ‘Step Down’ was actively being investigated.  The one element of resistance for residents was the distance to acute settings and in particular the lack of public transport links

·         A Member asked about delays in discharge from the Community Hospitals, to be informed that there were approximately 250 beds in the system at the present time and about 35 patients were currently medically fit for discharge

·         The availability of packages of care was a challenge, especially when a resident potentially required multiple people to attend the home multiple times a day, often in a rural setting.  It was reported that the market was currently being tested and it was not unusual for care providers to delay acceptance of a resident for a week or more   

·         A further challenge was patient choice, especially given the high proportion of self-funders

·         Members heard that for every additional week a patient stays in a hospital setting, they would see a year of decline

·         Staff wanted to help patients with rehabilitation, not provide a service which could be delivered more appropriately in another way

·         In relation to bed availability, at the present time there were 13 beds available across the Trust, with summer months having on average around 25 beds available

 

The Interim Strategic Director for People provided some clarity for the HOSC Members.

 

·         The Council had previously commissioned a dedicated ‘Step Down’ Unit at Red Hill, Worcester with around 30 beds.  Unfortunately, it had not worked as planned and was decommissioned around seven months ago

·         30 Care Homes were able to offer discharge on Pathway 3, i.e. patients with complex needs and unable to return to their usual residence perhaps requiring on going assessment.

 

When asked what WCHT would suggest could improve the current situation, it was suggested that a commitment to pre-order hours of domiciliary care and to generally boost the market would be most helpful.  This had been tested during the winter and freed up time spent seeking support for discharge.

 

The meeting was adjourned between 1:15pm to 2pm.

 

The Chairman welcomed everyone back to the meeting and reported that Mrs J Till was unavailable to attend the afternoon session.

 

Healthwatch Worcestershire

In attendance:

Jo Ringshall, Vice-Chairman

Margaret Reilly, Engagement Officer

 

Peter Pinfield, Chairman, had been planning to attend the meeting, but had unfortunately had to send his apologies.

 

Members were reminded of the role of Healthwatch, namely acting as the independent consumer champion, enabling local people to give feedback on health and social care services.  This was delivered through listening to patient views, visiting services to talk to people and making suggestions to organisations on how their services could be improved.

 

It was in 2015 that issues at WAHT were first raised and in the years following, Healthwatch had been involved with various Delivery Boards, Improvement Boards and had generally acted as a ‘critical friend’.  However, it was important not to forget that behind every statistic was a person.

 

Healthwatch had published a number of reports, some generic, some more targeted and follow up visits were undertaken to monitor progress of actions arising.

 

It was reiterated that Healthwatch did not take on individual cases, nor act as an advocate.  However, they did signpost residents to the most appropriate organisation.

 

In the discussion, the following main points were raised:

 

·         A Member asked whether Healthwatch was surprised that WAHT was continuing to underperform.  In response, it was reported that a variety of plans had been put in place, however, getting to a sustainable position was very difficult.  It was promising that the Executive Team was now more stable and it was hoped that policies and procedures could now have time to embed

·         Healthwatch Representatives were asked to describe what it was like visiting A&E at the two acute hospital sites.  Reference was made to the 2017 Healthwatch report ‘Care in the Corridor’ where 44 visits were made and 119 patients had been spoken to.  Generally, it was reported that obviously corridors were not the right place to be cared for, yet Staff were doing the best they could in difficult circumstances, but clear information and signage was lacking.  Healthwatch made recommendations and the resulting action plans were followed up in further visits.  In 2019, improvements were visible, such as all A&E Staff wearing purple uniforms, better signage and clearer information.  It was noted that these steps needed to be embedded into everyday practice

·         WAHT had also invited Healthwatch to undertake some research, most recently in the Fracture Clinic, looking at waiting times and alternative ways of delivering outpatient appointments.  Some quick wins were achieved, such as outpatient letters being given at time of discharge

·         Members noted that the Sustainability and Transformation Partnership was undertaking some work on outpatient appointments and whether these could be delivered through alternative channels other than face to face at the acute hospitals

·         When asked whether Healthwatch had undertaken any work on Discharge, Members learned they had not, but they recognised that there was an ongoing issue and patient flow work needed to be improved, especially in A&E, which was particularly small, especially at Worcestershire Royal

·         When challenged on the implication that the A&E department needed to be bigger, it was reported that this was one solution, however, there was a lot more important work on admission avoidance and prevention to be done

·         As an organisation, Healthwatch was a Member of the Health and Well-being Board and it sat on numerous groups associated with improving performance of the acute hospitals

·         When asked whether Healthwatch visited other hospitals to compare practice, it was reported that they did not.  However, they did share information across the Healthwatch West Midlands network

·         For clarity, Healthwatch reported that they did not look at personal information when making visits

·         When asked what one element HOSC Members should take from the discussion, it was reported that consistency was the key to success.

 

West Midlands Ambulance Service University NHS Foundation Trust (WMAS)

In attendance:

Mark Docherty, Director of Clinical Commissioning and Strategic Development/ Executive Nurse

Pippa Wall, Interim Strategy and Engagement Director

 

WMAS recognised the immense pressure that WAHT was under and reported that since WMAS had taken over the NHS 111 service in November 2019, ambulance attendance to A&E had fallen.  Past patient experience had suggested that if a call wasn’t connected via 111, patients would generally dial 999.  Now, just 15% of calls were converted to an ambulance response.  WMAS believed the new model was truly integrated and from Easter 2020, Staff from 111 and 999 would be working as one clinical team.

 

111 calls were generally answered within 22 seconds and 999 calls within 4 seconds.  Residents across the region were generally happy with the Service and very few complaints were received.  However, WMAS acknowledged that further improvements could be made.

 

It was reported that WMAS had made the commitment to purchase the buildings they used and therefore was able to invest in the Estate.

 

In the ensuing discussion, key points included:

 

·         A Member asked about the additional staff employed to input into the NHS 111 service, to be informed that there had been a commitment to employ 138 clinicians, in order that the service would have clinician input 24 hours a day, 7 days a week.  In fact, 142 Staff were employed.  This 24/7 support included not only General Practitioners but also other health professionals, such as Physiotherapists.  The flexibility offered by WMAS was an incentive to overcome perceived barriers in recruitment

·         Members heard that Paramedics in the field also had access to the NHS 111 clinicians

·         In response to a query about the computer system used by the 111 Call Handlers, specifically, the pathway through to treatment options, it was noted that the questions and algorithms had improved dramatically over time, however, the application of such a system was always important, hence why searching questions could also be asked

·         When asked whether the recent CQC activity was a surprise to WMAS, it was reported that all partners recognised that there were issues and it was important to acknowledge that in the first instance in order to move forward

·         Ambulance handover delays had a detrimental impact on the residents of Worcestershire if vehicles were stuck at Hospitals.  It meant that fewer ambulances were available.  Patient handover should occur within 15 minutes, as vehicles were designed for transport only.  Ambulance trolleys were not fitted with pressure mattresses, nor adequately heated.  WMAS believed that performance had slipped over the last 5 years

·         WMAS also believed that there was a good relationship between the Executive Teams and positive progress was being made.  The WAHT Chief Nursing Officer was very visible, although WMAS felt practices were not consistent.  An example was given of two dates 5 years apart where there were very few handover delays

·         When asked what WMAS could do to help, some Members noted that centralisation of services was causing concern, in part, as some patients could be conveyed to Redditch over Worcester.  Likewise, as 45% of 999 calls were for the frail elderly, having the Frailty Unit in Redditch was not a useful move.  Members were also reminded that WMAS had lost the Passenger Transport Service contract from 1 April 2020 and it was unclear whether the new provider would be able to respond as quickly as WMAS when it came to discharge patients

·         Rurality was not a factor in ambulance delays across the West Midlands region.  Shropshire had half the amount of delays as Worcestershire.  Leicester City Royal was usually top in comparison tables for delays and Worcestershire Royal ranked 5^th worst in the Country

·         It was felt more could be done to help Care Home residents, particularly those who were nearing end of life and had not arranged for their wishes to be noted.  Too many people were being conveyed to hospitals when their needs could be met at the Care Home with advice and guidance.  Members agreed that it was vital for residents to have those difficult conversations with family members and ensure that RESPECT Forms (end of life plans) were agreed in advance and known to those around them

·         In relation to Members hearing that tests undertaken on an ambulance were then repeated in the hospital and therefore perceived to be duplicating effort, it was clarified that the electronic record does not transfer across, however, the duplication was valid, in part, as the Hospital Clinicians were personally accountable and would wish for their own tests to be undertaken

·         WMAS recognised that WAHT had a mammoth task ahead of them, however, did articulate that there were some very good Staff.  Leaders should be held to account and one question posed was the position of where the surgeons were when surgery slots were cancelled.

 

Worcestershire Clinical Commissioning Groups (CCGs)

In attendance:

Mari Gay, Chief Operating Officer

 

The Clinical Commissioning Groups (CCGs) worked very closely with WAHT on patient flow to reduce demand across the acute hospitals.  There had been a 3% increase in attendance annually compared to the national picture and since April 2019, there had been significant demand in A&E across WAHT.  However, January and February 2020 saw a reduction in A&E attendance and a sense of stabilisation.

 

Primary Care was of good quality and the workforce was good.  GPs worked with acute consultants to speak about individual patients and the care around the patient had provided a model of two hour response in the community.

 

130 additional beds, compared to the number available 18 months ago, had been provided within the system in both acute and other settings and staff were being utilised to ensure patient flow.

 

Same day emergency care was a model which partners were working towards and discharges under Pathway 1 (discharge to Home) were seeing an additional 40 care packages per week.

 

In the ensuing discussion, the following points were made:

 

·         Ward Practice had to change.  Discharge should always be a priority and delays were easily overcome.  Examples included discharging earlier in the day or ensuring that tablets to take home were ordered and delivered from the pharmacy in good time

·         Likewise, conversations should be taking place on a very regular basis, including with family members, to highlight expectations and limitations

·         The CCGs believed that WAHT provided value for money and although expectations were not always being met, the approach had changed and become more robust and pro-active

·         The Worcestershire health economy recognised that it would require a collective effort to solve the ongoing issues.  A System Improvement Board had been formed following the latest CQC inspection and its task was to ensure rapid system improvements.  Membership included national and local experts

·         In response to a query about delayed transfers of care, it was reported that adult social care packages of care were becoming more complex, however, Worcestershire fared very well against comparator authorities

·         The point was reiterated that too many patients left an acute setting for a community hospital, delaying their journey home, or to the place they called home

·         Unfortunately, family members often caused discharge delays due to nursing home availability not always aligning with the family wishes – whether financially, geographically or bed availability.  Everyone acknowledged that these were difficult conversations to have, yet recognised that early discussion must take place and Members supported this view

·         Following the earlier discussion with WMAS Officers, a view was sought about perceived duplication of patient assessment and testing.  Members were informed that findings could well be very different once on site and for patient safety, it was a necessity.  However, there was a regional IT Strategy and partners recognised that the process could be improved, resulting in possible financial savings

·         Access to 4G and even 5G was improving across the County, resulting in better technological solutions

·         Members noted that the improvement journey continued and partnership working was a key component.

 

Worcestershire Acute Hospitals NHS Trust (WAHT)

In attendance:

Matthew Hopkins, Chief Executive

 

The Chief Executive was welcomed back to the meeting in order that Members could explore some of the themes coming out from the discussions.

 

The Chief Executive reiterated that WAHT was under constant scrutiny and challenge, yet Leaders were working tirelessly to improve and to ensure the Trust was clinically and financially sustainable

 

The following points were made:

 

·         In response to a question about levels of staff absence through stress, Members noted that there had been some stability in A&E resulting in less agency staff requirements.  This lack of a requirement to rely on a temporary workforce had improved attendance as there was a different threshold to attend, which was a national picture

·         Sickness rates across the Trust were at 3–3.5%, which was better than the West Midlands average and better than the 4% across the whole NHS

·         A Member referred to the increased number of ambulance conveyances year on year.  In response, the Trust highlighted for context that there had been 3,300 more ambulance conveyances to its hospitals between April 2019 – end January 2020 than in the same period in the previous year.  The Trust was pleased that the 111 service had been taken on by WMAS, however, the service was still being embedded.  It was hoped that numbers would decrease in time

·         In response to the queries about duplication of testing and generally improving technology, the Committee acknowledged that all organisations were keen to share information and that system wide digital developments would need to take place.  A communication system was being investigated which would highlight when a patient presented with symptoms which were not usual for them.  However, ultimately there was professional accountability to uphold

·         It was accepted that the NHS wasn’t always the most flexible of employers and in becoming so, the workforce may be keen to work in different ways.  This was a national conversation

·         Partnership working was key to providing system wide improvement.  An NHS Team of experts had been in assist with A&E, but improvements needed time to embed

·         The quality of care, once received, continued to be rated well and Board Members often worked on the shop floor to experience working in various environments

·         Staff across the organisation, doing the job, were best placed to improve working practices and this was recognised by senior leaders

·         Given the concern surrounding Coronavirus (COVID-19), the Government had suggested inviting retired clinicians back to work.  If this was the case, flexibility was key

·         Locally, plans were in place for an additional 10 critical care beds to be added, as part of the 33 already in place

·         The NHS 111 service was the first point of contact and a Coronavirus Hub had been set up to screen residents in a safe and secure setting

·         The Chief Executive reminded the Committee that regular hand washing with soap and water was key to stopping the virus spreading.  It was also hoped that in future, the take up of the annual flu jab would be higher.

 

The HOSC Chairman asked the Democratic Governance and Scrutiny Manager to share some themes from the day.

 

Recurring Themes:

 

·         Lack of Space, both generally and particularly in A&E departments, at the Worcestershire Royal Hospital, Worcester and the Alexandra Hospital, Redditch

·         Increase in demand, especially from frail elderly patients

·         Patient Flow

·         The Role of Community Hospitals

·         The need for End of Life planning and better promotion of the RESPECT initiative

·         Steps taken by all partners to reduce demand on A&E departments

·         WMAS taking on the NHS 111 service from November 2019

·         Digital technology and possible improvements to assist progress

·         Workforce, especially lower vacancy rates and developments with the University to aid their plan for a Medical School

·         £29m Capital Funding secured, yet business cases were still required for elements other than the Link Bridge at the Worcestershire Royal site

·         A £40m Capital Funding business case being developed.

 

HOSC Members also agreed to add the following Items to its work programme:

 

·         Onward Care Team – follow up session in three months

·         Developments in admission avoidance measures – follow up session

·         End of Life Planning (RESPECT) – overview session

·         Invite the Chairman of the System Improvement Board to a future meeting

·         Arrange a visit for HOSC Members to NHS 111 at WMAS HQ.

 

The HOSC Chairman thanked everyone who had participated in the extended meeting, in particular Matthew Hopkins, and was personally encouraged by what had been said.  It was anticipated that a future HOSC would be arranged to reflect on the themes from the day.