Agenda item

(Director of Governance) To consider the attached report and undertake appropriate external scrutiny of Princess Alexandra Hospital NHS Trust.

The Chairman introduced three officers from the Princess Alexandra Hospital (PAH) Trust. They were Lance McCarthy (Chief Executive), Stephanie Lawton (Chief Operating Officer) and Nancy Fontaine (Chief Nurse). They were there to respond to the concerns of the Committee in response to the concerns of Care Quality Commission (CQC) regarding aspects of its inpatient, outpatient and medical emergency services and other area of concern.

The PAH officers had been given a list of issues that the Committee wanted to cover and were asked to begin their response.

Mr McCarthy (Chief Executive) started off by referring to the strategic issues that affected the Hospital Trust. He noted that the trust was rated as inadequate and focused on their improvement plan for the CQC where they recommended ‘must dos’ and ‘should dos’. In total they had 38 actions/issues raised. That formed the basis of their quality improvement plan; but they also had over 600 other items that they had to consider and also to tackle any of the underlying issues to prevent them happening again. They have a good framework on theses actions and know everyone that would be leading on them. Reporting up to the executive team and then on to the Trust Board on a bi-monthly basis. Also, as part of being in special measures, they also have a monthly governance oversight meeting with the CQC and NHS Support.

They have a detailed structure in place focusing around the areas of most concern such as emergency care and end of life care. They were continuing to make really good progress against both of these. That was part of a general update of the improvement plan.

Ms Fontaine (Chief Nurse) noted the on receipt of the CQC findings they took an extremely serious view and took immediate action on the mortuary situation, where it was deemed to be substandard. It was important to known that there was at no point any detrition of any of their patients within that area. The capital programme for the renovation of the mortuary was programmed as a “to do”, but was delayed as the finance was needed for something else, but it was never not going to be done. The Human Tissue Authority, the authority responsible, inspected us in December and stated that we had met the required standards. That was important to note because around the ‘end of life’ issues it was around the mortuary service provision and resource. The Trust was now working with partners around Hertfordshire and Essex as well as Community Trusts who commissioned services from us. They have also appointed a specialist consultant clinician for ‘end of life’. The CQC had now commented on the compassionate care we now deliver. Although it was not always possible or in their gift to transfer patients to a hospice or preferred place of care that they wished to go to. And, according to their STP partners they were state of the art in that they were leading with their commissioners and Community Trust to get one standard across Hertfordshire and Essex; not an easy thing to do.

The Critical Care Unit was a shock; there were many areas where they were not performing as well as they should, such as the emergency department. But for Critical Care they had always met their clinical outcomes and their mortality outcomes and expected deaths care was always rated as among some of the best in the country. Looking at their figures, they tended to take in a wider variety of patients into their HD and ITU. The CQC were concerned about outcomes and delays in getting the patients out of the Critical Care unit. The Critical Care leads were honest about not pushing forward opportunities to be innovative and were probably sitting on their laurels and were now determined that at the next inspection they would be rated as good. It was important to note that all our intensive care patients were safe and we have managed to keep safety at the forefront.

We see about 109,000 patients a year through our emergency department, and for many of their patients they did not have any other out of hours facilities to go to. That was a long standing issue, outside of GP practices there were not many advanced practitioners working out of hours and at weekends, however they are working to create places for patients to go to throughout their sector.

The other area was around training, access to training and appraisals. We have put in a new system for statutory mandatory training and an appraisal system that was meaningful for all their staff.

Another area of concern was staffing across the board; not just nurses. We are close to London where they can earn more money and therefore recruitment and retention was tricky for PAH. We have put in lots of innovative approaches to recruitment and retaining staff, especially for nursing and doctors, both nationally and international recruitment. We have had a lot of successes and have received an outstanding for our maternity and gynaecology units and have bucked the national trend and do not have a shortage of midwives having only 4.5 vacancies. For theatres across the hospital we have one vacancy. There were areas that have been really successful in recruiting due to making sure that staff felt safe and patients felt safe.

Finally important to recognise that the CQC saw that there was a disconnect between the board and senior management around getting messages down to the staff. We have been working hard on staff engagement and now have weekly briefings. We are focusing on staff experience through listening events and focus groups, to let them know that they were listened to.

Councillor Murray had some concerns about a recent experience an elderly person had been asked by their GP to present themselves at the A&E department and had a five hours wait, with a further 3 hour wait before an allocation of a bed. He acknowledged that it was not an emergency, but it was about midnight when a bed was found for them. He would like to know if that long wait was typical. Also, when a family member asked if they could accompany the patient up to the ward they were told that they could not as it was against policy. Was it policy that a family member could not accompany them? He acknowledged that it was a good ward with good staff manning it. Ms Lawton (Chief Operating Officer) apologised for the length of the wait and noted that last week was a particularly challenging week for them. They were still struggling and were on averaging having between a high 70’s and mid 80’s percentages in achieving the 4 hour standard. Staffing was still a challenge in this area, particularly out of hours, but she could confirm that the patients remained safe within the department. They have also made significant improvements in flow and discharge coming down to only 4% in April. They were about to undertake building works and extend the department and make it easier and more accessible for patients.

Ms Fontaine added her apologies, saying that it was not their policy to not allow family members to accompany patients to the wards; in fact it was actively encouraged. They also have parking concessions and offer refreshments to the relatives who stay. So that was incorrect but she was glad to hear that the care was good.

Councillor Murray also had concerns accessing the wards from the A&E department for a relative. Ms Fontaine replied that they always tried to keep relatives with the patients.

Councillor Patel noted the actions they had taken after the CQC report was published, but what he wanted to understand was what analysis had the trust undertaken to determine how they ended up in that position. Also it was clear that some of the wards were performing better than others, so what action was taken in relation to the managers on the wards that were under performing. And regarding training, you have mentioned trying to get staff to do mandatory training, but he was not clear if it was e-learning or face to face training. And what follow up competency assessments were in place to ensure the staff understood the training. Ms Fontaine replied that there were ward differences, the medical and emergency wards fared pretty well, having a structure that supported accountability. We now meet all the teams on a three weekly cycle where they must have completed improved governance and innovation and commit to the best possible care. In terms of action take, it was more in terms of supporting and growing staff and making sure they had access to leadership, management and coaching and putting in a positive approach. As for training we have some e-learning and some face to face training, such as safeguarding children and adults.  They were also developing using a booklet with a series of test questions; and all of the clinical training had competencies attached to them anyway.

Councillor Knight noted that she had visited Harlow Hospital recently and was stunned by the good treatment she received. At the end she was referred to another hospital where the experience was not so good. She noted that over the years she had noticed that there was an inequality as to how you were treated from department to department and seems to be a kind of lottery depending on what was wrong with you on how you got treated. She also wanted to pick up on the percentage of staff retention; did you manage to keep your staff, were they enjoying their work and did they receive regular training to deal with managing people? Ms Fontaine thanked Councillor Knight for her compliments and said she would feed it back to the department concerned. She agreed about the inconsistencies, for example the improvement in the maternity department and in children services. As for long standing staff, Princess Alexandra was the highest employer and recruiter of all local staff. Many of our staff had been there for 30 years or more, with tranches of 40 or 50 years service; and it was not uncommon to have three generations of staff working there. They were also forging links with Epping and Harlow to recruit school leavers and also had an apprenticeship programme, which was key to developing people. There was a higher turnover of junior staff that tended to stay a short time and then move to London. But they tended to come back later after receiving speciality training in London that we could not give them. Our local hospital offered them a community sprit. Mr McCarthy added that they were doing extremely well, but the whole health service had difficulties in recruiting staff, especially when in special measures.

Councillor Neville asked if they could elaborate on the training they did on Safeguarding of Children. Was it on parity with the adult safeguarding and what about the use of agency staff and their training? Ms Fontaine said that there were problems with the accessing of training and the management and there had previously been failures to follow policy. It was not a matter of management support but a matter of culture and having them always thinking about safeguarding issues. We did a lot of work with our family doctors and staff and are always thinking Family, Children and Adults. We were now meeting all the standards and improvements in training and compliance has improved by 283% over the last six months, but we can never do enough.

Councillor Holly Whitbread wanted to know about local recruitment and what kind of relationship they had with local schools and colleges and also with their neighbourhood health centres and hospitals. Ms Fontaine noted that there tended to be a high turn around of staff locally when it came to other trusts. They carried out weekly interviews across the country and had recruitment events with universities and forged links with local colleges.

Councillor Baldwin asked if they had any strategy in place to reduce dependency on agency workers and to check on their competencies. Ms Fontaine said that that have written to all agencies and asked for the training background of staff. We will also have clear reduction in the use of Temporary staff. Mr McCarthy added that in 2015/16 they had spent about £20 million on temporary staff, the following year (2016/17) they spent £15 million and were heading for a £12/13 million expenditure for this current year.  This has been helped by a national focus on agency staff generally and pairing down the rates of these staff; they now have a tighter process in place on not breaking these caps. Also they were increasingly filling in the gaps with their own experienced staff, filling in at a lesser rate.

The Chairman noted that the meeting was straying into other areas other than the strategic ones and asked if Mr McCarthy would like to speak about any other issues he wanted to cover.

Mr McCarthy added that he was at a meeting this morning with the STP (Sustainability and Transformation Programme) board covering west Essex through to East Hertfordshire talking about competing with other Trusts for the same pool of staff and how they could work together as a combination of organisations across the area. They were talking about the potential setting up of an academy that could pool staff with certain skills, taking them from school up to employing them.

Ms Lawton added that during the inspection they were still in their recovery phase for our standards and procedures and an 18 week pathway on recovery. Pleased to say that since July last year they have achieved all their standards for 18 weeks, one of the few Trusts in the country to do this. For the last 18 months they have achieved all their diagnostics and cancer standards and are now advising other organisations on cancer standards. They are making really good progress on this.

The meeting was again opened up to questions from members.

Councillor Bedford asked how was the Trust affected by the recent cyber attack on the NHS and what had they learned from this. Also, on bed-blocking and the reported long wait between being discharged and actually leaving the hospital. Why did it take so long? Mr McCarthy said that the cyber attack had not affected them as their IT department found out early on about this and effectively pulled the plug on all external networks to stop the infection. The team then worked around the clock to patch up their existing systems and ensure future security, as far as they could. We also have a lot of relatively new equipment so were less susceptible than other organisations.

Ms Lawton replied to the bed-blocking issue saying that they had done a lot of work with Social Care and Community organisations to enable us to work together. They had an integrated discharge team now and they had joined a national campaign on this - ‘Red to Green’ on how they could improve their discharge processes; and they now plan 24 hours in advance. They also have their own discharge vehicle. It had not been cracked as yet, but it was tracked on a weekly basis and was still a work in progress.

Councillor Sartin asked about the time it took for ambulances to hand over at A&E, as referenced in the report, did it still take a lot of time to do so. Ms Lawton said that this was an area of concern. They now have a specialist doctor and nurse to receive patients coming in by ambulance and have see improvements over the last four months. They have also instituted monthly audits to look at the position and the improvements made.

Councillor Patel asked how they were dealing with social isolation within the community especially in regards to resident who were moderately frail and how were they supporting them in the aftercare. Ms Fontaine said that they had a frailty unit with frailty practitioners working with outside agencies such as social care and the Community Trust, constantly assessing the needs of the patients. The future would be reaching out into the community much more. There also have a lot of voluntary services that we worked with. Mr McCarthy added that they were formally working in partnership with other organisations in West Essex developing an ‘accountable care partnership’ an integrated way of working that went across the entire organisation and superseded the ‘silo’ mentality.  Ms Fontaine added that they also had a state of the art, virtual patient at home system, where our clinicians, nursing staff and support workers and pharmacists supported early discharge patients and supported them in their own homes.

Councillor Wixley asked if they had any emergency plans in case of terrorists attacks or disasters (especially as they were near Stanstead Airport), and was it tested regularly. Ms Lawton replied that they did have various emergency plans which were regularly tested and practiced every year. They were the emergency hospital for Stanstead and were in regular contact with them.

Councillor Lea noted that recently her husband had been to the hospital where he received very good care and she had no concerns over this or the care and professionalism of the staff. But, she encountered one member of staff there who was not conversant with English. No complaints other than she would like to know what sort of training staff got. Also, would it not help if you had a rehabilitation centre that was connected to the hospital to help the elderly patients on their release or even prior to it? Ms Fontaine commenting on the language said that all international doctors, nurses and support staff had to take a (difficult) test which they were required to pass in order to get registered in this country. As for people who live in this country and work here there is a language standard that they have to meet. Ms Lawton added on the rehabilitation issue that they constantly kept this under review and worked with a number of agencies looking at discharge and what support was needed. This was something provided although they did not have a rehabilitation centre, but they did work closely with the discharge teams etc. to co-ordinate and plan for any remedial treatment needed.

Councillor Patel asked if they were CQC ready now. Mr McCarthy said that they still had some challenges around urgent and emergency care and it also depended on what was meant by ready. He would hope and expect that we would get out of special measures by the CQC inspection.

Councillor Bedford noted that the Harlow hospital was built in the 1970’s and wanted to know if a new site had been identified and if funding was in place; and what would be done with the old site. Mr McCarthy said that they were going through a formal process to look at all the various options and were developing a strategic outline case to make a case for the requirement for a hospital in Harlow and then on to where and how it could be positioned and potential costs. In the long term we were maybe looking to rebuild on a green field site which would be better than patching the current site up. Rebuilding the hospital on it current site would be much more disruptive and more expensive and take much longer. The strategic outline case would need to go through several hurdles before it could be finalised, a final plan agreed and an outline business case developed.

The chairman thanked the participants for their attendance and noted that reading through the various report summaries the one thing that came through was that it was a caring hospital, so important for patients and that had come through this evening. She thanked them and wished them all the best for their future development.