Agenda item

Whipps Cross University Hospital provides a range of general inpatient, outpatient and other medical and emergency services to a significant part of the population of the Epping Forest District. The Committee has been extremely worried to read the recent report of the Care Quality Commission (CQC) on its ‘inadequate’ judgement of the quality of care at Whipps Cross Hospital, particularly in terms of the implications of the findings of the Commission for the healthcare requirements of the Council’s residents. A copy of the report of the CQC is attached as an appendix to this report.

 

Lyn Hill-Tout, the Interim Managing Director of Whipps Cross and Dr. Mike Roberts, the interim Medical Director at the hospital, will be attending the meeting to report to members in connection with Barts Health NHS Trust’s detailed plans for improvement in the areas of concern identified by the CQC. Jo Carter, the Trust’s Stakeholder Relations Manager, will also be in attendance.

 

Essex County Council has delegated its health scrutiny powers in the south of the county to the Outer North East London Joint Health Overview and Scrutiny Committee (HOSC). The County Council nominates one member to this body (Councillor Chris Pond) and this Council is able to also nominate one member representative to the HOSC, although this position hasn’t been appointed to in recent years. At the request of the Committee at its last meeting, a new member appointment was considered at the recent annual Council meeting.

 

Barts Health NHS Trust has indicated that it will provide its key local authority partners (including this Council and Waltham Forest and Redbridge London Borough Councils) with a regular report on the progress of its improvement plan for Whipps Cross Hospital. This will be published in the Council Bulletin.

The Committee welcomed Lyn Hill-Tout, the interim Managing Director of Whipps Cross University Hospital. She was there to report to members on Barts Health NHS Trust’s detailed plans for improvement in the areas of concern identified by the Care Quality Commission (CQC).

 

The Committee noted that Ms Hill-Tout had only been in post for 8 weeks, although she has had 42 years in the NHS and was last at the Mid-Staffordshire NHS Trust; she had retired two years ago but was very experienced in working with hospitals with damming CQC reports.

 

It was noted that:

·         the CQC inspection of Whipps Cross took place in November 2014 by a team of about 20 inspectors with different expertise;

·         five domains were used to rate the quality of services: safe, effective, caring, responsive and well led;

·         the overall CQC rating of Whipps Cross was ‘inadequate’;

·         4 warning notices were issued by the CQC plus specific compliance actions;

·         Key concerns arising from the inspections: insufficient staff levels; a persisting culture of bullying and harassment; bed occupancy that is too high; and a failure to meet national waiting times targets; part of these concerns related to the high levels of agency staff and low staff moral;

·         the four warning notices related to the following regulations: staffing; incidents and learning (staff did not feel that anything was being done); flow, escalation, end of life care; and complaints and PALS;

·         the four compliance actions related to safeguarding; consent; records; and equipment;

·         there were however areas of outstanding practice, one was the effective management of pain relief for children and adults; and their ‘Great Expectations’  maternity programme;

·         four major hospital services at Whipps Cross (surgery, critical care, maternity and gynaecology, and services for children and young people) were rated as good for delivering caring treatment;

·         other hospitals in the Barts Health (The Royal London and Newham) are also to be inspected and these report would form an overall Barts Health provider report;

·         the NHS Trust Development Authority (TDA) has now placed Barts Health in special measures;

·         these were designed to deliver service improvements at pace by providing support where it was most needed. Part of this support includes the appointment of an Improvement Director and the opportunity to partner with a high-performing trust;

·         staff were very relieved when that this report was produced as it highlighted their concerns;

·         staff were confused about who to go to with their concerns and this had resulted in the strengthening of site leadership;

·         they had now strengthened the site leadership team and Site Management Board at Whipps Cross and had put in site based leads for each of their Clinical Academic Groups;

·         there were similar models in place for The Royal London and Newham;

·         there would be staff events and open sessions to find out what needed to be improved;

·         improvement programmes would be developed in partnership with staff, staff representatives, patients and partner organisations;

·         Whipps Cross was still needed and has a future in providing acute healthcare to its local population, but has to change and a future strategy be developed;

·         They were committed to transparency with their stakeholders, staff and patients about their progress;

·         a lot of people look upon Whipps Cross as their local hospital and there was a lot of positive feedback form the local population;

·         they needed more staff and were currently recruiting and looking at how to retain staff;

·         they needed more quality staff and acknowledged that they have a high proportion of Agency Staff;

·         patients needed to be informed and engaged;

·         they would be putting out monthly summary reports online to share their progress;

·         informal briefings would be given as required;

·         other actions taken to date include:

Ø  partnership with staff-side representatives;

Ø  launch of the Guardian Service;

Ø  improvements to local induction process (especially for agency/temporary staff);

Ø  nurse establishment review completed;

Ø  safer staffing policy agreed with escalation plans in place;

Ø  red flag procedures in place to better understand impact of staffing deficits on safety;

Ø  educational/training programme in place for staff around safe staffing standards;

Ø  wards sisters to become supernumerary so that they are not expected to fill gaps in the rota and can concentrate on keeping up the clinical standards;

Ø  risk assess each ward to ascertain areas of greatest risk and need for extra staff;

Ø  they were looking to build a High Dependency Unit at Whipps Cross – this should be open by next Spring; and

Ø  and introducing “daily safety huddles” and ward safety briefings and senior leaders walkabouts;

 

A copy of her presentation is attached.

 

The meeting was then opened up to questions from members present.

 

Q.        With the hospital in a considerable deficit are you confident you can improve the hospital performance without increasing the deficit and if so, how?

A.        It could be done as cost and quality were separate; we could improve things without increasing the costs. This would not be easy but improving quality did not mean increasing costs.  We would be running a deficit this year of £134 million and were all very concerned about that level of deficit. Part of our strategy was to recruit staff and not use agency staff, improving quality and decreasing costs. Also, we get fined for not hitting our targets, so if they did, then this money would come back to us. This was a huge task as this was a large and complex organisation, but it was doable.

 

Q.        Can you explain how the previous management were seemingly unaware or unable to deal with the decline of care in the hospital?

A.        Whipps Cross had its difficulties for some time. This was part of the rational behind the merger with Barts Health Trust, the second largest in Europe, with a turnover of £1.2 billion. So this was a huge agenda in itself. There were also large and complex PFI deals within it as well of the complexity of arranging services within London, which is complex enough as well as the staffing issues to go with it. This agenda, for any organisation was too large (as well as introducing a new IT system), what they did was too ambitious and they were aware of some of the difficulties and were in part trying to address them through things like reviewing staff moral.  But this was not done in a very co-ordinated way nor was there any acknowledgement of the scale of what they were trying to tackle.

 

Q.        As a Loughton Councillor I have had good experiences of Whipps Cross, both for myself and my family. There are a lot of good people working there. But, this inspection report was one of the worst I have read in 30 years, with its focus on the culture of bullying and harassment. We have heard what you are doing to involve staff, but how wide spread was this culture of bullying.

A.        How widespread? It was in particular departments. We have a good sight on this now and were looking to give staff confidence and let them know who they could talk to. A lot of staff now come and talk to us with their individual concerns. There was a bad culture of people not talking to each other and not sorting out their problems. There was also a lot of interim staff and turnover, who did not understand the culture; there was a need for permanent staff not agency staff. This could not be changed overnight.

 

Q.        I was curious when you mentioned debts of £134 million, a lot of money; as well as paying fines. What was the impact on patients?

A.        We have a contract with our commissioners with targets. The new Chief Executive is talking with the Clinical Commissioning Group to see if we can put that money back, obviously with strings attached. We are fined if we do not meet standards set out in our contract and the fines go back to clinical commissioning groups, a bit of a nonsensical system and one of the contributing issues. But they are meant to be a driver for quality.

 

Q.        You have also mentioned taking on an additional 500 members of staff, is there enough money to do that as that would be quite expensive.

A.        It is indeed and that is what is contributing to the £134 million deficit. But that is such an important part of what we do, so we have to address that. Also, as a trust we have a large PFI; there were a lot of concern about these both nationally and locally. Yes, we have invested in nursing, but that was a necessary investment and in the long term this would save money. Once we get the right staff in place we will not be paying the high agency fees.

 

Q.        I have found out that a lot of people do not know how to use your IT system, and when it does not work there was no backup system, with no support in place. Also one management at the top level was always changing. Each time staff comment they ask for it to be anonymous, so I am worried there was still this fear of bullying around.

A.        I think you are right. In the eight weeks I have been there I have not been able to resolve all those issues. I get staff coming to talk to me but not wanting to give their names; which says something about the culture. That’s one of the reasons we set up the Guardian Service.  There was still work to be done to make sure people know who to go to if they have an issue. We will be putting up contact details etc. to encourage staff and to let them know who to go to. We know we will still have a huge amount of work still to do with staff, and I’m not saying that it was fixed by any means.

 

You were right about management changing, we have had a series  of interim people, and I am interim myself, which worries me, as the way people build relationships was by not having constant change.

 

Our IT system was still not working well; we still have some down time. Other than staffing, IT was probably the biggest factor we have to tackle. I am not disagreeing with anything you said as it rings a bell with me. There is IT backup and I will provide a written answer around the backups on this.

 

Q.        I'm also concerned that in the paediatric unit, in the urgent and emergency care, it was pointed out that there were no paediatric nurses on staff at various points when there should be a minimum of two at all times. What plans does this trust have to make sure that doesn't happen again?

A.       Recruiting paediatric nurses was a problem nationally and we lost a number of our senior paediatric nurses when there was a regrading of nursing posts, people are still very angry about that as they feel that those issue were raised at the time the regrading was done. One of the benefits of working in a large organisation, like Barts is that we try to give new paediatric nurses more experience across all our sites. We have also had a campaign with adverts put in the specialist paediatric journals and have had two new nurses start at Whipps Cross, which was a start. We also have a programme of rotation of senior nurses into the paediatric area to build the confidence of ‘adult’ nurses in paediatric care. We also have a transfer nurse on staff every night to facilitate the transfer of patients into the paediatric ward.

 

We have shut six of our paediatric beds because of staffing issues and will be splitting our wards into higher and lower dependency units and hope that this would attract nurses.

 

Paediatrics is one of those areas where we fall down, partly because we cannot get children admitted to a paediatrics ward as soon as we would like and partly due to the loss of six beds. But there was a whole raft of work happening around paediatrics.

 

Q.           What about the high profile resignations from the trust; were any compensation payments awarded above what they were contractually entitled to?

A.           I can confirm that compensation payments were made.

 

Q.           A&E provision at Whipps Cross. In the neighbouring Trust - Barking, Havering, Redbridge University Hospitals Trust (BHRUT) there was an issue about the A&E closing down at King Georges. I ask this question because I am aware that residents in the south of the district sometimes receive treatment at King Georges Hospital at Goodmayes in Ilford and Queens Hospital in Romford (whose A&E unit was also not performing well). I believe that until Queens was performing well, King Georges would not close. When it does this would result in extra pressure on the Whipps Cross A&E, which in itself is not as good as it should be. He was wondering with the closure of 1 in 3 A&E departments, how would Whipps Cross cope with that?

A.           No specific date has been set for the closure of the A&E Department. The Trust is working with the commissioners and with Barking, Havering and Redbridge. At Whipps Cross we will need to increase capacity and staffing before this closure happens. Currently we are not performing as we should be and need to address these problems before this happens.

 

Q.        You mentioned the recruitment of 500 new staff and the shortfall of nurses. This would imply recruiting from, probably, outside Europe as well as within. What training, over and above the normal would you provide?

A.        There will be 500 nurses for Barts Health, which is in addition to the normal vacancies that we have and that would be an additional 108 for Whipps Cross. They will have local induction training and Trust induction training, of 3 days duration. This would be along with ongoing appraisals by ward sisters.

 

Sometimes overseas nurses do not feel as welcome in the workforce as they should. We try and support them. We also focus on retention of staff which is really important.

 

Q.        What about this 7 day week currently being pushed by central Government.

A.        There have been a number of attempts to encourage doctors to do a seven day week. We have consultants there seven days and are talking to our senior consultants to facilitate this. We are looking to extend this to the doctors and are looking to put in a 1 in 10 week rota (for weekend working) from the present 1 in 20 week rota as it is now. We are making good headway with this and will have an agreement within the next eight weeks. If we do this we would also need to keep the diagnostics departments open 7 days a week and be able to discharge patients on weekends.

 

Q.        A lot of mistakes were made under the merger where there was a lot of financial pressure. Also a lot of the staff had a rough time under this merger. I would be interested to know if there was any additional management training provided, as good management skills would make it so much better.

A.        The downgrading had a long lasting effect and we lost a lot of good staff. Management training is happening; we are making sure all our staff has appropriate training from senior managers down to ward staff.

 

Q.        We are in an odd position with A&E hospitals situated around our boundaries but not within the district. I have had bad experiences of Whips Cross and feel that they had no accountability to this district. As Councillors how can we feed in constructive criticism to you?  (It was noted then that we have Councillor Chris Pond on the Essex County Council Health Scrutiny and Councillor Chambers was on the Joint Health Committee).

A.        I am sorry to hear of your experiences with us. You can use ‘Health Watch’ or the Joint Health Scrutiny Committee, the Oversite Scrutiny Committee group for Whipps Cross. We can also continue to come and engage with you here. And I also offer an invitation that you can also contact myself and my colleagues and we would respond to you.

 

Q.        I am concerned about introducing another tier of management into your organisation also about staff retention; agency staff earns more from one night shift than permanent staff earn in a week, also there is the matter of the extortionate agency fees. I do not see how we can rectify the situation.

A.        There is a national fuss in the media about this; the minister said that we need to take action about the employment of agency staff. There needs to be more system wide management of this by the NHS. We are building our existing workforce and a bank of staff who wish to do overtime and could step in and fill gaps. We are looking at giving enhanced rates for the ability to work in any area and are trying to think of initiatives which can improve the situation.

 

In terms of managers managing others, you’re right. We shall reviewing this and looking at who we have.

 

Councillor Mohindra asked if Ms Hill-Tout could come back to this committee and give them an update on progress made. This was agreed by the Committee and will be factored in to a future meeting.

 

The Chairman in winding up the debate thanked Ms Hill-Tout for her interesting presentation and for answering the questions so well and congratulated her on the work done so far.