Agenda item

·         Whittington Health NHS Trust

·         North Middlesex University Hospital NHS Trust

·         Royal Free London NHS Foundation Trust

Whittington Health NHS Trust

Sarah Wilding, Chief Nurse & Director of Allied Health Professionals at Whittington Health NHS Trust, provided a short summary of draft Quality Accounts for the Trust. She explained that the Quality Priorities established in 2020 had been extended from three years to four years as it was recognised that, due to the Covid-19 pandemic, it would take longer to embed change. However, there had also been a stakeholder consultation process to ensure that the current priorities were reflective of the current need. Previous progress against the Quality Priorities was set out in section 3 of the report.

Sarah Wilding then responded to issues raised by the Committee:

• Asked by Cllr Connor about the reasons for changes to priorities and targets, Sarah Wilding explained that there had already been progress in some areas but also because of developing an understanding of where the organisation currently was, including through feedback from the consultation and other data.
• Cllr White highlighted services to help people manage long-term conditions such as type 1 diabetes which included contact with doctors, dieticians and other people with the same condition. He considered that investment in this kind of support network for people with long-term conditions could help to improve health outcomes and reduce future costs to the NHS and asked how this was addressed through the Quality Accounts. Sarah Wilding agreed that there were multiple examples of investing up front in health promotion and long-term support leading to people living longer and healthier lives. She said that this was only ‘nodded to’ in the Quality Accounts but that there was a lot of ongoing work with patient engagement and experience which was developing these kind of opportunities. A new Head of Patient Experience had recently been appointed to progress this work. Investment needed to be targeted and there were examples set out in the Quality Accounts such as improving quality of care for patients with sickle cell disease.
• Cllr Connor asked whether there was collaboration between hospitals on specific areas of work, such as those described in the previous answer on health improvement. Sarah Wilding responded that there were more opportunities to work at a system level across different organisations and that this was part of their ongoing work. She said that that there were strong links with UCLH on patient pathways, including the realignment of cancer pathways and having the right staff in the right place. Another example was partnership working with UCLH on patients having elective Caesarean sections where there was more capacity at the Whittington, so UCLH (University College Hospitals London) patients could choose to use the facilities at the Whittington and there were collaborative conversations between the two Trusts on improving these services. In addition, the Chief Nurses from different Trusts met on a regular basis with projects across the system (e.g. enhanced care for patients with mental health needs) looking at how best to standardise and learn from one another.
• Cllr Milne commented that engaging with ‘hard to reach groups’ had been a problem referred to in health interventions for decades. Sarah Wilding acknowledged that it could be exceptionally difficult, but that targeted work tended to make a difference.  The CQC had recently delivered an inspection report on maternity services at the Whittington and they had since worked with the Maternity Voices Partnership to help understand all women that were giving birth at the Whittington need so that they had the best experience possible. Another example was patients with mental health that were also linked to chronic disease as they were being seen in pathways, so it was necessary to ensure that staff are skilled in supporting these type of vulnerable patients. Cllr Milne added that not accessing services seemed to be crucial, perhaps due to transport issues or a poor understanding of the health system. Sarah Wilding responded that transport services were outsourced and this had not been without problems which is why it was important to ensure that vulnerable patients had the right support. The organisation had also lost many volunteers since the Covid-19 pandemic and so there was a need to replace these to improve support and wayfinding for patients.
• Referring to the summary of CQC report (page 19 of the supplementary agenda pack) Cllr Connor requested further details on the Trust’s response and actions to improve services. In relation to the CQC report on maternity services, Sarah Wilding said that they had been disappointed with the overall rating but that there was some outstanding practice within the report. She added that only the safety and leadership elements had been rated and not the other three domains which would have resulted in an overall rating of ‘good’ rather than ‘requires improvement’. However, there were areas to improve upon such as training so there had been catch up sessions and work to make training as easy as possible to access. Some policies and procedures were not as up to date as they should have been and so these were being modified as quickly as possible. Another issue was insufficient differentiation in triaging and so the team had worked to improve the system with a red/amber/green priority system. There were also issues around the condition of the estate, including the bereavement suite, and this was part of the ongoing refurbishment drive with maternity services. Finally, there had been a problem with hot water in Simmons House that had now been resolved. All of these issues were monitored through governance structures.
• Asked by Cllr Connor about the other CQC inspections referred to in the table on page 19, Sarah Wilding explained that the only recent inspection had been on maternity services, whereas the others referred to the existing rating status based on inspections from previous years. Cllr Connor commented that it would be useful to include a brief explanation of this in the report, including links to reports and details of actions being taken in response. Sarah Wilding explained that there was a regular governance meeting that oversaw all of the actions needed in response to the findings of the 2020 report, most of which had been completed. However, she accepted that more information about this would be useful.
• Referring to the section about clinical audits in 2022/23 (page 12 of the supplementary agenda pack) Cllr Connor requested further clarification on the End of Life Care Audit which was the only national audit that the Trust did not participate in. Sarah Wilding explained that this was because there was such a short timeframe between getting the results and making the improvements so it had been considered better to focus on the areas that were known about rather than to restart many other things. There were also staffing challenges at that time, though this had now improved. The expectation going forward was that the Trust would comply with all the standards on all of the national audits, including end of life care.
• Referring to the CQUIN goals (page 18 of the supplementary agenda pack), Cllr Connor noted that the issues relating to CQUIN04 (Compliance with Timed Diagnostic Pathways for Cancer Services) were contained in a separate document linked to on that page. This stated that “There is currently a lack of focus on the pathways. In many cases the required diagnostic tests and actions are currently happening, but not within the required timeframes and in some cases possibly not in the right order, making achievement of faster diagnosis standards less likely.” Cllr Connor suggested that issues such as this should be highlighted in the report itself as this was otherwise difficult to find. Sarah Wilding agreed to take this issue back to the Medical Director. (ACTION)
• Referring to the electronic booking system for the Wood Green CDC (Clinical Diagnostic Centre) (page 18 of the supplementary agenda pack), Cllr Connor said that some residents did not have access to electronic booking and asked if walk-in options could be made available. Sarah Wilding said that she would need to look into this and come back to the Committee. (ACTION)
• Referring to the aim of reducing unnecessary hospital admissions through supporting patients in their home environments (page 7 of the supplementary agenda pack), Cllr Connor noted that “up to 28 Virtual Wards would be utilised including 8 technology enabled virtual ward patients” and asked for further details, including whether this was a shared resource.  Sarah Wilding confirmed that the Trust did provide services for NMUH and UCLH and the aim was to get patients out to their own homes where they clearly did much better and there had been some specific work on the delirium pathway which had good success rates in patients not having to be readmitted.
• Cllr Connor queried the low scores in many areas of the National Cancer Patient Experience Survey (page 37 of the supplementary agenda pack). Sarah Wilding acknowledged that the cancer patient experience was not where it needed to be and it was recognised that the timing of this was during the Covid-19 pandemic where there had been more fragmentation of services. The Trust was working with UCLH to strengthen the pathways. There had also been significant gaps in some of the senior nursing leadership posts but a new lead cancer nurse had been appointed which would help to drive improvements. There would also be a focus on hearing the lived experience of patients.
• Cllr Milne referred to a graph of referrals to the Trust’s palliative care team (page 22 of the supplementary agenda pack) and asked why there had been a significant rise in 2022/23 both in terms of numbers of cases and complexity of cases. Sarah Wilding said that this was partly because of the decline of mental and physical health resulting from the Covid-19 pandemic and from people not accessing treatment and health networks, particularly people with long-term health conditions. The increase in referrals was positive in a way because it meant that symptoms were being controlled in patients with complex needs, including pain relief and psychological support.

Cllr Connor thanked Sarah Wilding for attending, acknowledging that there were many positive aspects to the report which there had not been time to cover, and said that some further questions would follow by email.

Statement provided from JHOSC to Whittington Health NHS Trust

The Joint Health Overview and Scrutiny Committee for North Central London would like to thank Whittington Health NHS Trust for their engagement and assistance regarding the Quality Accounts, including the sharing of a draft version of the report and attendance at a scrutiny meeting of the Committee.  The Committee also wishes to place on record its thanks for the hard work of staff throughout the Trust in 2022/23 in delivering positive health outcomes for our residents at a time when the NHS is under considerable pressure.

As part of our scrutiny, the Committee welcomed the focus on tackling health inequalities and further efforts in supporting ‘hard to reach groups’ to engage with services. The Committee commented that the quality of transport services available to vulnerable residents could be a key factor in this area along with their understanding of points of access to services.

The Committee also welcomed measures taken on health promotion and expressed support for the further development of support networks for people with long-term conditions which could help to improve health outcomes and reduce future costs to the NHS.

The recent opening of Community Diagnostic Centres in Finchley and Wood Green has helped to improve access to blood tests, x-ray, ultrasound and ophthalmology services. The Committee recommended that consideration be given as to whether accessibility could be further improved by providing additional options for patients who cannot access electronic booking systems.

The Committee highlighted certain areas where additional information could be included in future Quality Account reports. In particular, the Committee suggested that the Trust’s responses to the findings of CQC reports and issues relating to CQUIN goals could be more clearly explained.

The Committee discussed the response to the CQC report on maternity services and noted that maternity services across NCL were due to be scrutinised by the Committee in more detail as part of its work programme for 2023/24. Other issues and areas of concern raised by the Committee included collaboration between hospitals, the End of Life Care audit, virtual wards, the National Cancer Patient Experience Survey and the increase in referrals to palliative care.

The Committee looks forward to further engagement with the Trust on these issues in 2023/24 and through the scrutiny of next year’s Quality Accounts report.

North Middlesex University Hospital NHS Trust

Sarah Hayes, Chief Nurse and Vicky Jones, Medical Director for the North Middlesex University Hospital NHS Trust (NMUH) provided a short summary of draft Quality Accounts for the Trust. They highlighted Section 1 of the report which included the Patient First Strategy and Section 4 of the report which looked at progress made against the previous year’s Quality Priorities, details of the Patient Experience Strategy and results from CQC inspection reports. It was noted that the draft Quality Accounts report and the draft annual report were merged as one document and some of the draft annual report had been redacted as it was not ready for publication.

Sarah Hayes and Vicky Jones then responded to issues raised by the Committee:

• Asked by Cllr Connor whether the Disability Ambassador roles (referred to on page 95 of the supplementary agenda pack) it was explained that this was a staff role resulting from the strengthening of staff networks. Sarah Hayes and Vicky Jones confirmed that this was linked to the work being done to promote better accessibility for people with disabilities.
• Cllr Milne asked for further clarification about the use of the A&E department at NMUH and observed that a culture of needing instant solutions was contributing to the increase in the number of Emergency Department visits. It was agreed that this could be a factor and that, in addition, the Emergency Department was sometimes used by people instead of accessing primary care, for example because of the difficulty in accessing or taking time off for a GP appointment or having come from a country where the structure and expectations of health services were different. Providing practical advice to promote self-management was an area of work aimed at improving this, including helping parents to self-manage but also to spot the signs where medical help was necessary.
• Cllr White referred to the aim of reducing the prevalence of smoking in Enfield and Haringey by 25% by 2025/26 page 95 of the supplementary agenda pack) including by providing evidence-based advice on stopping smoking. Cllr White suggested that people who smoke are typically aware of the health risks and that other interventions such as peer-based support would be more effective. Sarah Hayes and Vicky Jones explained that the focus in the previous year had been to train staff to have that conversation and to signpost people to support. While it wasn’t possible to provide direct support within the hospital, it was possible to take the opportunity to have the conversation and direct people to support elsewhere in the community.
• Cllr Connor asked about data/performance measures, referring to the 25% smoking cessation target and the Key Performance Measures set out in the report (page 112 of the supplementary agenda pack), the majority of which were red. Cllr Connor said that it was not clear how these measures would be addressed and suggested that this information should be included in the quality account reports. This also applied to the CQC ratings (page 122 of the supplementary agenda pack). (ACTION)
• Cllr Milne observed that the Trust had participated in a total of 57 national clinical audits and national confidential enquiries during 2022/23 (page 135 of the supplementary agenda pack) and noted that this must require significant staff resources to complete.
• With regard to “Never Events”, of which there were four incidents in 2022/23, (page 128 of the supplementary agenda pack), Cllr Connor asked for further details on the information that was collected to ensure that learning was embedded. It was noted that there had been a recent learning event on this topic and that there were also safety actions, observational audits and governance processes to drive improvement.
• Cllr Connor referred to the patient experience section of the report noting that, while the number of complaints seemed to be high, it would be useful to be able to compare this to pre-pandemic figures and requested that further data be provided in the following year’s Quality Accounts report. (ACTION)

Cllr Connor thanked Sarah Hayes, Chief Nurse and Vicky Jones for attending and said that there was a lot of positive information in the report. She added that any additional questions would follow by email.

Statement provided from JHOSC to North Middlesex University Hospital NHS Trust

The Joint Health Overview and Scrutiny Committee for North Central London would like to thank North Middlesex University Hospital NHS Trust for their engagement and assistance regarding the Quality Accounts including the sharing of a draft version of the report and attendance at a scrutiny meeting of the Committee.  The Committee also wishes to place on record its thanks for the hard work of staff throughout the Trust in 2022/23 in delivering positive health outcomes for our residents at a time when the NHS is under considerable pressure.

As part of our scrutiny, the Committee explored the considerable demand at the Emergency Department and advocated the promotion of self-management where appropriate and helping people to spot the signs of when medical help was or was not required.

With regards to complaints data, the Committee recommended that information should be provided on trends over a longer period of time in future Quality Accounts reports.

The Committee also noted that, as some targets were not being achieved according to Key Performance Measures set out in the report, further explanation of how these measures were being addressed by the Trust should be included in future Quality Accounts reports.

Other issues and areas of concern raised by the Committee included the new Disability Ambassador roles, advice for patients on smoking cessation, the embedding of learning after the four ‘Never Events’ that occurred during 2022/23 and participation in national clinical audits.

The Committee looks forward to further engagement with the Trust on these issues in 2023/24 and through the scrutiny of next year’s Quality Accounts report.

Royal Free London NHS Foundation Trust

Gillian Smith, Interim Chief Medical Officer at the Royal Free London NHS Foundation Trust, provided a short summary of draft Quality Accounts for the Trust noting that it included a continuation of some of the priorities from the previous year with a few new priorities added. There was a key theme of improving learning from incidents and other safety events and patient involvement was another area that would be a key priority for the year. She acknowledged that, while there was a priority around having no “Never Events”, there were unfortunately a number of Never Events that took place during the time period of the report and so there had been a focus on capturing and embedding the learning from these, including through a large cross-Trust learning event in December. A new safety incident response framework would soon be implemented nationally and this would represent a big change in the way that quality issues were approached. 

Gillian Smith then responded to issues raised by the Committee:

• Asked by Cllr Connor whether there had been any measurement of data on the patient experience priority, Gillian Smith responded that they were at the point of implementing some of the initiatives but there wasn’t any data coming through yet.
• With regards to the eight Never Events (referred to on page 186 of the supplementary agenda pack), Cllr Connor requested further explanation on why there had been so many of these. Gillian Smith explained that there were some themes around the processes in place to prevent Never Events and it was recognised that these processes had not been sufficiently embedded and implemented. There was therefore renewed focus on strengthening these processes which included forms of checklists before interventional procedures for example. They had also reviewed how to audit these processes to ensure that they were being correctly implemented.
• Cllr White asked how the wider determinants of health, including health promotion and supporting people to manage chronic long-term health conditions, were reflected in the Quality Priorities. Gillian Smith responded that the two main areas in the report relevant to this were the embedding of primary prevention and a significant potential impact of secondary prevention. The Trust was trying to use opportunities for secondary prevention when people were in contact with services, an example of this being the healthy living hubs. Secondary prevention methods were also embedded in digital care pathways. There was also work to drill down into waiting lists and identify health inequalities. Cllr Connor suggested that it would be useful to see details about this in future quality account reports. Gillian Smith agreed with this and noted that the details were included in other documents such as clinical strategies.
• Referring to Priority 1c on conversations with patients about care in the last year of life (page 174 of the supplementary agenda pack), Cllr Milne asked about the benefit of training and information for staff on this. Gillian Smith acknowledged that these were very difficult conversations and said that staff felt more confident and comfortable having those conversations after they had received the training. There was also evidence that patients and families felt better prepared for the final months of life if that conversation was had effectively and could minimise potentially unpleasant interventions such as inappropriate resuscitation calls for example.
• Referring to Priority 1b on nutrition and hydration (page 192 of the supplementary agenda pack), Cllr Connor asked who was responsible for patients eating properly in hospital settings. Gillian Smith said that attention to hydration and nutrition was an important part of the basic care offer to patients and feedback from patients, families and staff. She acknowledged that this was not always being done right which was why it had been identified as a priority so that processes on the wards were being delivered correctly. Cllr Connor requested that further details on how this was being carried out and who was responsible for ensuring that this was being done correctly on the wards be included in the following year’s report. (ACTION)
• Cllr Connor noted that the Trusts had failed to meet the standard to see at least 93% of patients within two weeks of a GP cancer referral. Gillian Smith said that, in common with many other Trusts, they had not yet achieved the cancer standard in terms of the post-pandemic recovery. There was a Trust-wide cancer programme with various recovery interventions and they were working closely with the North Central London Cancer Alliance.
• Cllr Connor asked why the children and young people’s patient experience survey had not been carried out in 2022/23 (referred to on page 244 of the supplementary agenda pack). Gillian Smith said that she would find out the reason for this and get back to the Committee. (ACTION)

Cllr Connor thanked Gillian Smith for her attendance and said that any additional questions would follow by email.

Statement provided from JHOSC to Royal Free London NHS Foundation Trust

The Joint Health Overview and Scrutiny Committee for North Central London would like to thank Royal Free London NHS Foundation Trust for their engagement and assistance regarding the Quality Accounts including the sharing of a draft version of the report and attendance at a scrutiny meeting of the Committee.  The Committee also wishes to place on record its thanks for the hard work of staff throughout the Trust in 2022/23 in delivering positive health outcomes for our residents at a time when the NHS is under considerable pressure.

As part of our scrutiny, the Committee advocated the greater use of health promotion and supporting people to manage chronic long-term health conditions and suggested that further details on actions in this area should be included in future Quality Accounts reports.

The Committee welcomed the inclusion of improving nutrition and hydration for inpatients as a new priority for 2023/24 and recommended that it should be clearer as to who was responsible on wards for ensuring that patients were eating properly. The Committee suggested that further details on this should be included in future Quality Accounts reports.

The Committee raised the issue of the two-week cancer referral target of 93% not being met. This was understood to be an issue in common with many other Trusts in terms of the post-pandemic recovery. The Committee was assured that there was a Trust-wide cancer programme with various recovery interventions and that the Trust was working closely with the North Central London Cancer Alliance.

Other areas of concern raised by the Committee included measurement of data on the patient experience priority, procedures to reduce ‘Never Events’ (of which there were eight in 2022/23) and training for staff on conversations with patients in the last year of life.

The Committee looks forward to further engagement with the Trust on these issues in 2023/24 and through the scrutiny of next year’s Quality Accounts report.