The Chair welcomed NHS colleagues from Imperial College, presenting the Quality Account 2016/17. Professor Julian Redhead, Medical Director explained that the Trust’s Quality Strategy 2015/18 was the vehicle by which they hoped to achieve quality goals, supported by annual targets and a number of improvement programmes. They had incorporated an extended timeframe in order to ensure that there were opportunities for the document to be publicly reviewed and consulted upon, with the first draft circulated on 4th April 2017. The report was shorter and easier to read and presented an overall picture of what was one of the safest hospitals. While there was a high rate of reported incidents, there was by comparison a low harm rate.
With reference to the Referral To Treatment (RTT) rates, Councillor Carlebach understood the pressure that the Trust was operating under but observed that while some rates were good, 62.62% for Dementia was poor. ‘Access to Cancer Services, 62 day wait for first treatment from urgent GP referral’, was in Q4, 74.7%, having progressively decreased from earlier quartile performances. Professor Redhead accepted that the Trust had struggled to meet standards for specific reasons including late referrals from tertiary providers, despite their intent to be patient-centric. They had put in place measures that would improve patient pathways, however, the key was to have in place effective preventative measures and earlier diagnosis to ensure that patients received the best treatment.
With reference to End of Life care, Councillor Carlebach enquired about what steps had been undertaken to address this particular need. Professor Redhead acknowledged that there was a need to bring together all sectors from primary to acute trusts, wanting to ensure that patients where not unduly distressed. Councillor Carlebach expressed his thanks to health colleagues for the commitment and performance of staff at Imperial.
In response to a query from Bryan Naylor, it was explained that the Trust was in the same position as many organisations, responding to the uncertainties and difficulties of Brexit, and they were doing their best to reassure staff about this. In terms of recruitment, the Trust was also trying to ensure minimum standards for staff to communicate clearly and effectively with patients. The hospital was a multicultural environment, with multi-lingual staff which was helpful in terms of understanding cultural differences and having effective communication.
The discussion continued, focusing on the education and training provided to health staff, to ensure that they were able to access career pathways, upgrade their skills and develop relevant expertise in areas that offer them job satisfaction. It was noted that this was a long term programme of on-going development, which could take up to three years for the benefits to materialise.
Bryan Naylor highlighted concerns reported by Age UK members about discharge protocols for patients, their carers’ and families and allegations of “bed blocking”. Prof. Tim Orchard responded that this was an important issue for the Trust. Patients were admitted from a range of different areas, for example, Adult Social Care, district nurse or GP referrals. This potentially required them to liaise with a number of different groups. The West London Alliance pilot project meant that a social worker was directly accessible on site, so that the process of putting in place support services in preparation for discharge could commence far more quickly and effectively. Craig Williams confirmed that the Council had worked collaboratively with the Trust, with social workers taking on specific responsibility for residents in LBHF, and similar, reciprocal arrangements operated with the other partner councils such as Ealing.
It was reported that there had been improvements, with the achievement of a reasonable level of discharges. However, it was important to be able to measure or assess the time taken for the discharge process, in order to obtain a clear picture. The Community Independence Service was a key component of the discharge protocol and the Council worked closely with Imperial on this. It was important people were assessed properly prior to discharge. A member of the public expressed concern about premature discharge from the Charing Cross site, undertaken late at night. Professor Redhead confirmed that they would normally discharge vulnerable patients during daylight hours only and offered apologies on behalf of the Trust. A member of the public added that the experience of having access to a social worker on site had been extremely helpful and positive.
Councillor Vaughan made reference to patient transport (page 45 of the Quality Account document) and the FFT (Friends and Families Test) results which had been reported as “consistently below target”, noting the measures put in place by the Trust to address this. Professor Redhead acknowledged the significant difficulties that they had experienced in monitoring the key performance indicators (KPIs) for a service which had been contracted out. Councillor Vaughan indicated that it would be useful to come back to the issue, once the new service protocols had been embedded. Acknowledging a point made by Councillor Coleman, Professor Redhead accepted that the Trust would be ultimately responsible for the activities of failing contractor.
Action: Update on patient transport services, Imperial
A member of the public commented that Charing Cross hospital was a busy site and suggested that another urgent care centre similar to one in Parsons Green be opened, alleviating the need to visit a GP and to stop people from having to visit the hospital. Professor Redhead responded that part of the issue was the lack of resources and funding for Adult Social Care and the need for improved patient pathways. In response to a query from Councillor Coleman, Professor Redhead confirmed that the cost of keeping a person in hospital was approximately £500 per day, varying according to the extent of the illness and treatment required, rising to £2500 per day, on a rising scale for an intensive care bed depending on the treatment.
Continuing the discussion on financial implications Councillor Vaughan enquired in particular about changes to charges for non-European patients. Councillor Coleman also enquired about the current vacancy rates, broken down by hospital site. Professor Redhead reported that the vacancy rate was more or less similar across the whole organisation, with rates specialities finding it particularly challenging to fill roles.
Focusing on the issue of training, Professor Redhead asserted that the Trust as an employer had a responsibility to put in place measures to improve work based training opportunities. It was reported that since Brexit, there had been a 96% fall in applications for nursing posts, although he speculated that in part this could also be attributed to short term planning. He suggested that the way to address this was to establish a system of statutory, national training, incorporating appraisal protocols, work based training, prioritising student recruitment and retention and work closely with nursing colleges. Professor Redhead stated that up to a quarter of nursing students were unsatisfied with training and that there was a challenge to striking the right balance between the needs of students in training and of patients.
Professor Tim Orchard, continued the discussion, observing that with medical student training, there was now a move to increasingly greater classroom and bedside training, provided by dedicated teaching fellows. He anticipated that this would temper the experience of students on initially entering the hospital environment. Advocating the need for statutory mandatory training, he stated that this was an important issue for the Trust, with ward based training offered as support for student training and development.
With reference to earlier discussions on RTT, it was noted that there were government penalties for missing the 52 week waiting list target. Councillor Vaughan speculated that there was a broader issue here linked to internal target monitoring, with a lack of incentives.
A member of the public reported an on-going situation at the warden controlled housing in which they lived. This was noted as a safeguarding issue, to be addressed directly by officers outside the meeting.
Councillor Vaughan enquired if the Trust had been affected by the recent cyber-attack experienced by recently by a number of NHS bodies and the implications for maintaining future cyber security. Professor Redhead confirmed that they had not been directly affected. The virus had affected older operating systems and that the Trust had (prior to the incident) invested in upgrading their operating system. In terms of future defences, it was reported that it would be very difficult to anticipate, predict and prevent the impact of any similar occurrences. Although the IT department of the Trust operated strong firewall protocols, it was difficult to maintain robust security in an open system.
With reference to CQC Councillor Vaughan enquired about the digital elements of outpatient booking appointment system. It was noted that the choose and book system was available through most GP surgeries and the Trust confirmed that they had recently introduced a more efficient electronic data retrieval system which made it easier to find old medical records and letters.
With reference to page 43 of the Quality Account, Councillor Vaughan enquired about patient safety issues, in particular, pressure ulcers. Additionally, he asked about “never events” (defined as serious incidents that were entirely preventable, if recommended protocols and guidance are followed) and the targets set out in page 63 of the Quality Account. It was noted that while staff reporting rates had improved and that the rates of “never events” had reduced. Shona Maxwell explained that the target figures continued to reduce by 10%, with a reduction of 26% evidenced during 2016. It was noted that this was a ‘stretch’ target.
Professor Redhead clarified that the learning obtained from “never events” had been utilised within the surgical department, with core themes around patient safety protocols being developed. He acknowledged that previous surgical checklist protocols had not been robust. In response, the Trust had in November 2016 undertaken proactively safety improvement work in theatres, from which point, he reported that there had been no further “never events” recorded, to date.
With reference to page 55 of the Quality Account and the section on Well-led quality highlights, Councillor Vaughan asked about the low scores related to staff experiences and reporting of violence at work. 31% of staff surveyed had experienced harassment, bullying or abuse, against an average of 25% nationally. Professor Redhead explained that work was being undertaken to address this such as more training for managers and promoting general awareness of dignity and respect at work, improving general engagement with staff. The Trust took its legal duty to ensure a safe working environment for its staff very seriously. While violent behaviour or abuse in some environments, such as A&E was not condoned, it was anticipated, usually with underlying mitigating factors. There was a need to ensure that staff are not placed in any danger and do not put themselves at risk. Work had been undertaken so that staff were able to respond to security alerts and that emergency and contingency planning was sufficiently robust, given recent events. In response to a query from Councillor Coleman, Professor Redhead explained that they had established that incidences of staff bullying by colleagues largely related to emotional bullying.
Referring to an earlier point on the FFT, Councillor Vaughan sought an assurance that the qualitative data available from the survey could offer robust evidence. Professor Orchard explained that the data was taken on a monthly basis, ward by ward, and triangulated with patient responses from a detailed questionnaire to see if there was any correlation between satisfaction levels and the recording of serious incidences such as pressure sores. Each individual was invited to complete a scorecard and scorecards were taken from each directorate. Professor Orchard reported that they would go through the findings on the scorecards and that this also offered a robust metrics system. Identified problems were routinely escalated outside this framework and much of the development work undertaken to address behaviour concerns was through training and education. This was a complex area, requiring a structured programme of change within the organisation, ensuring that the Trusts’ values and ethos regarding respect and valuing diversity, were shared by staff. It was noted that many of the reported incidents took place during transfers or the handover of patients to staff and Professor Redhead acknowledged that this an area in which they would need to work much harder.
While it was noted that patients were not discharged unless post-medical care was in place, Councillor Coleman enquired how the Trust measured patient discharges and the level of post-medical care required. Professor Redhead acknowledged that this was a good point but confirmed that there were no performance indicators in place to measure this. He explained that it was difficult and could not commit to putting in place any such measures but would be happy to discuss this in more detail.
A member of the public commented that if everyone contributed £5 per person, this may help address the financial difficulties currently faced by the NHS. She offered to donate her recent £100 lottery ticket win. Both Imperial and Council colleagues, were touched by this warm gesture and thanked her, her for very generous and kind donation.
It was noted that the earlier publication of the draft Quality Accounts had provided an opportunity for sufficient to time to provide feedback. The Quality Accounts covered all areas of the Trusts work and Councillor Vaughan thanked the Trust for a candid and open report, despite the fact that it had missed a number of targets. He asked that the Trust bring back the following areas for more detailed discussion:
On behalf of the Committee and the residents of Hammersmith and Fulham, Councillor Vaughan expressed his thanks to the Trust, for the invaluable work and support undertaken by their dedicated and hard-working staff.