Agenda item

·         North London NHS Foundation Trust

NOTE: This report is currently a draft version as there are sections to be added prior to the publication of the final version, including the feedback from the JHOSC.

The Committee received details of the Quality Accounts of the North London NHS Foundation Trust for 2024/25 from Vincent Kirchner (Chief Medical Officer), Manny Gnanaraj (Chief Nursing and AHP Officer), and Mandy Stevens (Interim Director of Nursing – Quality Governance).

Vincent Kirchner highlighted some key points from the draft report:

• The North London NHS Foundation Trust (NLFT) had been officially established on 1^st November 2024 following a merger of the two mental health trusts in North Central London (NCL).
• A set of six new Trust Values had been established following workshops, feedback sessions and surveys involving over 600 staff.
• Recent progress on estates had included the opening of Highgate East in March 2024, a new 78-bed mental health inpatient facility, and the opening of Lowther Road, a new Integrated Community Mental Health Centre in April 2024. Highgate East had recently won an award at the European Healthcare Designs Awards.
• There had also been progress with person-centred care planning through DIALOG+ which supported personalised, proactive conversations to empower service users to take charge of their recover journey.
• Through the Longer Lives initiative, more than 60% of people with serious mental illness had a physical health check in 2024-25, exceeding the national target. This involved collaboration with GPs and aimed to identify issues such as metabolic disease, lung disease, cancer and tobacco dependence in people with serious mental illness.
• The Trust was committed to a Trauma-Informed approach with an active Trauma Informed Collaborative and plans to roll out ‘Schwartz Rounds’ in 2025/26 which provided opportunities for staff to reflect on the emotional impact of experiences at work.
• The Trust’s four Quality Priorities for 2024-25 had been:

o   Providing consistently high-quality care, closer to home.

o   Working in partnership across North London to ensure equity of outcome for all.

o   Offer great places to work, providing staff with a supportive environment to deliver excellent care.

o   To be more effective as an organisation by pioneering research, Quality Improvement and technology.

Manny Gnanaraj set out the Trust’s four Quality Priorities for 2025-26, which had been developed following consultation and engagement with staff. The four Quality Priorities included carrying forward two of the Priorities from 2024-25:

• To continue to learn and develop as an organisation from patient and carer feedback.
• To ensure patients receive support in a therapeutic and safe environment.
• Offer great places to work, providing staff with a supportive environment to deliver excellent care.
• Providing consistently high-quality care, closer to home.

Vincent Kirchner, Manny Gnanaraj and Mandy Stevens then responded to questions from the Committee:

• Referring back to the priorities raised by the Committee the previous year, Cllr Connor said that the lack of supported housing for post-discharge patients had been a concern. She noted that this was referred to in the 2024/25 draft Quality Accounts but did not include any specific plans or collaboration with local authorities to address this. Vincent Kirchner said that it was acknowledged in the draft report that people who were Clinically Ready and Fit for Discharge (CRFD) but were unable to leave hospital was often due to issues with onward housing or accommodation and support. Asked by Cllr Connor about the potential to push for more accommodation at the developments at St Anns and St Pancras, Vincent Kirchner confirmed that the Trust did advocate for more accommodation, not just for patients but also for staff, but noted that what was delivered was driven largely by the commercial modelling for the projects and that there had been little recent progress in this area. Cllr James highlighted the importance of supported accommodation being included in the Local Plans produced by local authorities and the London Plan produced by the Greater London Authority (GLA). Vincent Kirchner added that it was not just additional building that was required but also the support from the local mental health team to provide services to the patients who had been discharged. Cllr Connor proposed a recommendation that there should be further liaison between the Trust and the GLA on the need for increased levels of supported housing and community support. (ACTION)
• Cllr Connor referred to concerns raised by the Committee the previous year about long waiting times for mental health services and noted improvements in early intervention, psychosis targets and a reduction in out of area placements. Asked by Cllr Connor about the specific data on this, Vincent Kirchner said that there was data in the draft report on talking therapies and the early intervention service but acknowledged that data had not been included on the waiting times for the neurodevelopmental service which were poor. Mandy Stevens commented that there were initiatives to support people while they were on waiting lists.
• Referring to the graph on page 27 of the draft report (Inappropriate Out of Area Placement – Occupied Bed Days), Cllr White commented that the narrative in the text did not explain the reasons for the substantial changes in the number of bed days highlighted in the graph. Vincent Kirchner said that, over the long-term, the level of Out of Area Placements had been substantially reduced with efforts to do things as efficiently as possible at every stage of the admission pathway. This included a new model of care for inpatient services with daily decision making on discharge and a focus on issues that could be an obstacle to discharge. He added that this was in the context of a growing population and greater demand for mental health services, so it was a significant achievement to bring these numbers down. The Committee recommended that the report should include more data on the key waiting times and KPIs as well as information to explain the long-term context for this. (ACTION)
• Cllr Connor said that another issue raised the previous year had been on the integration and communication between services on patient care, particularly with GPs at the point of discharge. Vincent Kirchner said that he did not have hard data on this but noted that knowing who to share information with typically changed depending on the severity of the patient’s illness. In complex cases this would be increased and fed into structures such as the MASH, MAPPA or MARAC where appropriate. Assessing the appropriate level of information sharing should be done through the person-centred care planning process. He acknowledged the issue of carers and families feeling excluded from this process and that teams were encouraged to do this when possible, but that the rates for this were not specifically measured. He noted that the information-sharing regarding working-age patients could be more difficult than in cases involving children or older people. Cllr Connor recommended that the rates for information sharing with carers and families should be measured and included in the Quality Accounts in future. (ACTION)
• Cllr Connor raised access to services for diverse communities as another issue that had been discussed the previous year, including language services. Vincent Kirchner said that language was not a specific metric that had been looked at but that there was a focus on disproportionate restrictive practice, particularly black men being detained under Section 136. He emphasised that the issue of race and the experience of people in contact with services was a top priority currently. Cllr Connor commented that it was difficult to ascertain progress in the current draft report and recommended that metrics to measure this should be included in future. (ACTION)
• Referring to page 7 of the draft report, Cllr Connor noted the intention to strengthen partnerships with local authorities and the voluntary sector on mental health care and highlighted the ongoing challenges faced by the voluntary sector on short-term consultation and the need for improved communications with them on finance issues. Vincent Kirchner said that the Trust offered 3-year contracts in contrast to the 1-year contracts offered by local authorities and added that there was collaboration with voluntary sector partners to evolve services in a sensible way. He also emphasised the benefits in working with the voluntary sector, for example with peer working and connecting with communities. Mandy Stevens referred to the neighbourhood model and community hubs as ways that voluntary sector partners were embedded into the local partnerships. Vincent Kirchner said that the voluntary sector partners were also involved in social enterprises and the delivery of employment opportunities. Cllr Connor commented that there were no KPIs on the neighbourhood model within the draft report. Vincent Kirchner said that more people were being seen through the core teams and that there was an increased range of opportunities available to people, which could be demonstrated. The greatest impact was through the individual placement support service. There were also targets for employing local people. Manny Gnanaraj added that people with lived experience were encouraged to take up opportunities with the Trust or other partners to help improve services. The Committee recommended that details of the neighbourhood model and metrics to measure progress be included in the Quality Accounts. (ACTION)
• Referring to individual cases involving patients, including people with mental health difficulties who were in touch with their local Councillors, Cllr White queried what more could be done to strengthen a joined-up approach between the Trust and local authorities. Vincent Kirchner responded that there was a good record of joint working in this area, including on social issues such as with benefit claims or housing issues but that the ambition was to break down barriers more effectively and consistently. Cllr Connor commented that the local authorities also now had neighbourhood teams and so it would be useful to understand through the Quality Accounts how they interacted with the Trust’s neighbourhood model and whether there were gaps that could be addressed further (both by the Trust and by local authorities). (ACTION)
• Cllr Connor raised concerns about patients in the community who had stopped taking prescribed medication and queried how a multi-agency response to this would be triggered. Mandy Stevens responded that there were clear guidelines on 72-hour follow up when people were discharged from hospital to ensure that they were stable, had the right support and the right medication. There were also Community Treatment Orders (CTOs) to enable the close monitoring of higher-risk people in the community. Cllr Connor suggested that there ought to be a red flag on the system that could be added by a community nurse or other professionals in order to prompt action. Vincent Kirchner said that a community nurse could write to the GP to set out concerns but that this did not always happen. Records and progress notes could also be shared on the London Care Record, but he acknowledged that this was not a flag and that there was a challenge involved in having multiple electronic patient records with systems that did not speak to one another. Cllr Connor proposed a recommendation for this issue to be considered in more detail so that action could be prompted when a professional become aware that a patient had stopped taking their medication. (ACTION)
• Cllr Atolagbe spoke about a local case involving mental health concerns but without suicide risk and asked how people in such circumstances could access services given that this would not reach the threshold for support through the Crisis Line. Vincent Kirchner said that the Trust’s service offer was for people at any stage of mental health and not just those experiencing crisis. Most people tended to access services through their GP who would refer to the core community mental health team. There was a governance process to monitor use of services including through an integrated service report which was monitored directly by the Board. He confirmed that phone calls to the service were monitored for performance reasons. Manny Gnanaraj added that the 111 – Option 2 service was another route to reach services. Cllr Connor commented that the Committee had previously raised concerns about the high threshold of the Crisis Line and that people may not necessarily be aware of other routes to access services. She recommended that the Trust should check that appropriate signposting was being delivered through the Crisis Line. (ACTION)
• Referring to page 13 of the draft report, Cllr Connor asked whether further details of the draft NLFT Carers Strategy with Healthwatch Islington were available including the key themes and commitments. Mandy Stevens said that further detail could be added to the report. (ACTION)
• Referring to page 14 of the draft report, Cllr Connor requested further information about the NLFT’s CQC inspection in February 2025. Mandy Stevens explained that there were eleven core services in the Trust, one of which was adult acute wards and these had been inspected. While the report was not yet available, there was always regular contact with the CQC on their regulatory oversight and there had been some specific interim feedback from the CQC after this inspection, but nothing was escalated and there were no improvement notices. The final report would be published in the public domain later in the year, but there was no confirmed date for this. She added that the interim feedback had been verbal at this stage but that a little more detail could be added to the draft report. (ACTION) Cllr Connor asked for any other relevant information about CQC inspections or oversight to be included in the final report.
• Referring to page 63 of the draft report, Cllr Atolagbe requested further details on the mentoring programme for underrepresented groups. Vincent Kirchner explained that this programme had been operating in the past year and that the Trust monitored the ethnicity of staff in different bands within the organisation. The Trust had one of the most diverse NHS Boards in the country but there was still some underrepresentation in higher bands. The impact of the programme would take some time and it was agreed that an update could be added to the following year’s Quality Accounts report. (ACTION)
• Referring to page 16 of the draft report, Cllr Atolagbe requested further details on the point that care for older adults had been improved by “creating consistent and clear needs led criteria across NLFT”. Vincent Kirchner explained that historically there was a cut-off age of 65 with people over this age directed to Older Adults services. In Camden and Islington this had shifted to a needs-based criteria, for example if there was a dementia diagnosis. However, in Barnet, Enfield & Haringey the criteria was still based on age so, following the merger, there had been work to move to a needs-based criteria in these Boroughs. The support from the Older Adults service was different because of the expertise on physical health. Cllr Connor requested that this explanation be included in the final report. (ACTION)
• Referring to page 19 of the draft report on the Quality Priorities, Cllr White suggested that there needed to be a clear way of measuring progress between now and next year. Mandy Stevens explained that there had been an extensive engagement progress to select the Quality Priorities. The specific aims under each Quality Priority had not yet been established and so this was a work-in-progress item, but there would be further details set out in the following year’s Quality Accounts report. (ACTION)
• Referring to page 21 of the draft report, Cllr Connor asked how the Local Clinical Audit Programme led to improved outcomes. Vincent Kirchner explained that quality improvement projects were all data-led to improve an aspect of the care that people received. Clinical audits also helped to maintain standards, such as with different aspects of care on the wards which could be monitored through the governance process and then interventions made where necessary. Mandy Stevens said that some examples of this could be included in the final report. (ACTION)
• Referring to page 24 of the draft report, Cllr Connor asked how the Performance Measurement Developments worked in practice. Mandy Stevens explained that this referred to the whole range of performance measurement, adding that the NHS was moving away from RAG (Red, Amber, Green) measurements in favour of SDS charts (Services Data Set) which showed improvement or decline over time with upper/lower control limits to trigger action. Cllr White observed that the SDS charts in the draft report illustrated a 2-year period but that it could be more useful in some cases to illustrate a longer period. Vincent Kirchner said that the inclusion of 2-year charts was a pragmatic decision but acknowledged that, in some cases, it would be possible to identify other trends over a longer period of time. Mandy Stevens added that the performance indicators were published in the quarterly public Board papers. Cllr Connor suggested that this explanation be included in the final report. (ACTION)
• Asked by Cllr James about Patient Safety Incidents, Mandy Stevens explained that the chart on page 42 of the draft report appeared to indicate that the situation had got worse but the reason that the figures had gone up was that there had been a lot of work to improve recording culture and to ensure that no and low harm incidents were recorded. No harm incidents were 64% and low harm incidents 31% of all patient safety incidents in 2024/25 which indicated that staff were taking the time to record these. She added that the Serious Incidents referred to on page 49 of the draft report indicated moderate harm or above and that the draft report included a summary of key learning and improvement actions that had been implemented as a result of the investigations. Vincent Kirchner added that harm on these incidents was not necessarily caused by the organisation and included any type of harm. Mandy Stevens explained that Patient Safety Incidents were reported in detail to the Quality and Safety Committee which was chaired by a non-executive director and attended by Board Members and patient safety partners. This enable themes and trends to be identified and inform changes to services. Cllr Connor suggested that changes to services that resulted from this process could be included in the final report. (ACTION)
• Cllr Atolagbe requested further details about the response to the challenges illustrated by the various performance graphs on pages 33 to 35 of the draft report. Vincent Kirchner responded that:

o   The Liaison Emergency Department Response Rate was consistently meeting the targets and this was maintained through monitoring.

o   The Crisis Resolution & Home Treatment (CRHT) Response had declined and there was a piece of work underway to standardise the crisis response team model across the Trust area and increase the staffing establishment which should bring rates back to where they needed to be. This was a good example of a breach of the control limits prompting action.

o   The 72-hour follow-up chart showed that levels were below the mean level but still within variation. Process problems had been identified, including discharge on a Friday and that the electronic patient record system was not always being correctly completed to alert community teams. Changes were therefore being considered to make certain fields mandatory on the system. The 72-hour follow up was important as this was a high-risk time for suicide.

Cllr Connor added that it would be useful to be able to follow up on progress against these indicators when scrutinising next year’s Quality Accounts report. (ACTION)

• Referring to the section on talking therapies on page 29 of the draft report, Cllr Connor noted that the agreed target for treatment completions for the year had not been met with three out of four boroughs behind plan. Vincent Kirchner said that there were quite high access targets, but that referrals continued to be lower despite work to raise the profile of the service. Cllr James questioned whether people knew that they could self-refer to the service. Vincent Kirchner commented that GPs were the largest source of referrals to the service.
• Referring to the section on the Friends and Family Test feedback on page 41 of the draft report, Cllr Connor noted that the details of the responses had not been included so it was not possible to ask any questions on this occasion. 
• Asked by Cllr Connor about the Community Mental Health Survey on page 41 of the draft report, Mandy Stevens confirmed that details of the findings would be included in the final report.
• Asked by Cllr Connor for further details about the Service User and Carer Engagement and Experience section on page 39 of the draft report, Vincent Kirchner explained that an area of concern was the self-imposed 40-60 working day target to respond to complaints which the Trust was struggling to meet. This was because complaints were often complex and time-consuming, so a more streamlined process was being looked at.
• Cllr Connor reiterated that further details on the metrics and KPIs used for evaluation in the Quality Accounts would be useful in terms of scrutiny from the Committee in next year’s report.