Agenda item

Dr Phil Barnes (Medical Director, Medway NHS Foundation Trust) and Mark Morgan (Interim Director of Operations, Medway NHS Foundation Trust) Patricia Davies (Accountable Officer, NHS Dartford, Gravesham and Swanley CCG and NHS Swale CCG), Dr Fiona Armstrong (Clinical Chair, NHS Swale CCG) were in attendance for this item.

(1)       The Chairman welcomed the guests of the Committee and asked them to introduce the item. The representatives from Medway NHS Foundation Trust began by updating the Committee on the four main issues at the Trust: Quality Improvement Plan, Transforming Medway Programme, CQC regulatory action and Governance.

(2)       The Quality Improvement Plan was produced to deliver the six recommendations arising from the Keogh Review in July 2013. Under the six recommendations 50 targets were produced; 90% of these had been completed or on track to be finished by the end of March. There was an emerging view that whilst the Trust would deliver the Quality Improvement Plan, the plan may not deliver a high quality acute hospital. There was a need for strategic focus to examine and deliver the Keogh, Francis and Berwick Reports; Urgent & Emergency Care Review and operational pressures.

(3)       A new strategy, Transforming Medway, had been developed by the new executive team, following the decision not to proceed with the merger with Darent Valley Hospital. The strategy had the broad support of stakeholders and regulators. The strategy focused on seven high priority and high impact projects. The absolute priorities for the strategy were to improve the Emergency Care Pathway and to provide an excellent patient experience.

(4)       To improve the Emergency Care Pathway, the Trust planned to create a single acute admissions area. Hospitals nationally had found that emergency care delivered in one area had improved the flow of patients, reduced length of stay, improved quality and mortality rates. At present, the acute medical unit in the Emergency Department had only sixteen bed spaces rather than the 65 – 75 beds required; other areas of the hospital were frequently opened up for acute admissions. The Trust was also piloting seven day services, recruiting staff and re-designing medical rotas to ensure senior doctors were at the front end of the patient pathway.

(5)       To improve the patient experience, customer service issues such as car parking, appointment letters and the physical environment were being investigated to ensure a good healing experience for the patient; in addition to the concerns regarding quality and mortality rates.

(6)       In regards to CQC regulatory action, Maternity Services provided by the Trust were inspected unannounced in August 2013. A number of significant issues were raised in the CQC report; the most pressing being staffing levels. A compliance notice was issued by the CQC which was met by the December deadline; the Trust now met the best practice levels of staffing. Maternity Services had not been revisited by the CQC but will be the focus, alongside the emergency department, of a forthcoming major inspection by the Chief Inspector of Hospitals.

(7)       An unannounced inspection of the Trust’s emergency department was carried out by the CQC on 31 December 2013. New Year’s Eve had been one of the busiest nights for A&E in recent years and the Trust had requested a divert, as the department had been so busy, but this had not been possible to be put in place. The inspection found significant breaches in infection control and cleanliness. The Trust accepted the findings in full and agreed an action plan with the CQC which were implemented by 28 February 2014.

(8)       The emergency department was treating upwards of 90,000 patients a year in a building designed for 50,000 patients. The A&E department at Queen’s Hospital in Romford was facing a similar challenge. Local media reported that Medway NHS Foundation Trust was the most challenged and worst performing in regards to length of A&E wait in January. An Executive Director of the Trust was physically on-site seven days a week; a significant amount of work had been undertaken to support the A&E department. For the last four weeks, the Trust had been running in internal incident mode with a tactical command team to improve emergency patient flow. By the end of March, the Trust was hoping to meet the 95% target of patients seen within four hours; last week’s performance was 93.7%. Performance targets relating to infection control and elective surgery in non-emergency departments had  been met.

(9)       Increasing staff levels had come at a significant cost. The Trust had initially forecasted a small deficit (£1.2 million) for the year 2013/14; the cost of additional staffing has increased the projected deficit to £7.9 million by the end of the financial year. Improvements in quality and the use of new pathways could reduce future costs.

(10)     The governance of the Trust had recently changed with the appointments of interim Chief Executive, Nigel Beverley and interim Chairman, Christopher Langley. Nigel Beverley was an experienced Chief Executive who was previously interim Chief Executive at Ipswich Hospital NHS Trust. Christopher Langley was an experienced Chairman who had helped turnaround two Foundation Trusts: Heatherwood and Wrexham Park Hospitals NHS Foundation Trust and Rotherham NHS Foundation Trust. Apologies were given on behalf of the interim Chairman and interim Chief Executive who were unable to attend this item on the Committee’s agenda.

(11)     Members of the Committee then proceeded to ask a series of questions and make a number of comments. A question was asked about the sudden escalation of A&E attendances. Trust representatives explained that a significant increase had taken place in the last 10 -11 years across all Trusts. One of the issues for the Trust was that the emergency department was seen, both by users and members of staff in the hospital, as the place people should go. Improvements need to be made internally to ensure patients who require medical assessment, go to a medical assessment unit rather than the emergency department. For the public, the emergency department was a place known to provide 24/7 care.

(12)     The Trust was looking at the whole of the urgent care pathway with Swale and Medway CCGs. There had been early discussions about an urgent care centre – a new build which would provide additional capacity. Patients would initially be seen by a specialist nurse or GP who would direct the patient to the most appropriate service. The Trust recognises that it was not in the best interest of the patient to be hospitalised; better joined up working would enable the delivery of services at home.

(13)     In response to a specific question about seven day services; it was explained that Medway NHS Foundation Trust was selected to be one of thirteen Trusts to gain pilot status for seven day services. The Trust was developing plans and staff models to deliver seven day services focused on quality. Members expressed concerns that seven day services could place additional stress on the system.

(14)     A Member expressed concern about the exclusion of finance as a key theme in the Quality Improvement Plan (QIP). It was explained that the QIP was developed with the regulator before the new management structure was in place; finance was not chosen to be one of the key themes of the plan. The additional transitional and on-going costs (£6 million) resulting from the Keogh Review correlated to the increased projected deficit from £1.2 million to £7.9 million. Following the Keogh Review, there was now an understanding across Trusts nationally that staffing levels should not be reduced to balance the budget; other efficiencies needed to be identified. Different forms of reorganisation were being investigated including vertically integrating community and social care services to deliver healthcare savings. There was also a national challenge to deliver and share services across larger areas to make them more sustainable.

(15)     A further question on the provision of shared services was asked. The Trust has been in discussion with the CCGs about developing shared services; building on the cancer and vascular services provided in Medway to patients from Maidstone and Tunbridge Wells and parts of Dartford and Gravesham.

(16)     A series of questions were asked about the leadership of the Trust. The new Chairman and Chief Executive had introduced a new management structure. Senior doctors were now responsible for the four business units focusing on three main areas: planned care, unscheduled care and cancer services. One of the immediate changes in the last month was that senior leaders had been requested to work across the whole organisation. An example was given; the Division Director for Surgery traditionally focused on planned care but was now additionally looking at the provision and delivery of unplanned care.

(17)     A new team had been set up with the CCG, the Integrated Discharge Team, which had brought together health and social care teams to support the discharge of patients over the winter period. 20% of patients required additional support at home after being discharged. Different services had been working much more cohesively to deliver a better patient experience.

(18)     A number of questions were asked about complaints, morale and winter pressure. It was explained that there were two key areas for complaints in Medway:  communications and clinical care. There was a peak of complaints in January, when the hospital was at its busiest, many relating to the emergency department. The change of leadership had not been the only issue to affect morale. Scrutiny of the Trust has affected morale on the floor and in the boardroom. The absolute number of patients in A&E has not been as great as in previous years. However it has still been a busy winter with the acuity of patients being greater than normal.

(19)     A series of further questions were asked about the upgrade to the Medway Emergency Village and triage. It was explained that the plan for the implementing the Medway Emergency Village was complex. Areas of the emergency department were being cleared, refurbished and put back into use as part of a sequence of moves. The Vanguard Unit, the temporary outbuilding was providing additional capacity during the upgrade.  At present A&E could  only triage patient to services within the hospital. The proposed Urgent Care Centre would be able to extend the hospital’s ability to signpost to services such as social services, community wound management services and community diabetes services.

(20)     Representatives from NHS Swale CCG were asked for their comments. Dr Armstrong explained that the quality of care and safety of patients in Swale was a key aim of the NHS Swale CCG; the CCG would like Medway NHS Foundation Trust to become a beacon of excellence and the hospital of choice. The issues at Medway could not be solved by the Trust alone. The CCG were working with the Trust, GPs and the public to develop a wider integrated primary care team enabling care in the community to work alongside hospital care. Ms Davies explained that it was important that quality improved at Medway; providing good basic care to the community. Trust finances were a concern for the CCG; the CCG were working closely with Monitor on this. There is a risk that if CCG finances need to be utilised to improve the financial position of the Trust, it would reduce the CCGs ability to invest in community care.

(21)     RESOLVED that the guests be thanked for their attendance and contributions today,  they be requested to  take on board the comments made by Members during the meeting and that the Committee looks forward to the interim Chairman and interim Chief Executive attending the meeting of the Committee on  5 September 2014.