Agenda item
IMPROVING QUALITY AT BARTS. HEALTH NHS TRUST
Minutes:
7.1 The Chair stated that Barts Health issues generally came to INEL because their services crossed all of the 4 boroughs as well as Waltham Forest. She stated that there were ongoing concerns about quality issues at the Trust and reminded Members that City and Hackney CCG had written to the Trust during the summer raising serious concerns about quality standards and since then there has been the publication of the National Cancer Patient Survey where the Trust did not do well.
7.2 Members gave consideration to the “Update Report from Barts Health” and the Chair welcomed to the meeting Dr Steve Ryan (Medical Director), Ms Karen Breen (Director of Delivery and Improvement) and Mr Mark Graver (Head of Stakeholders Relations and Engagement).
7.3 Dr Ryan and colleagues took Members through their report. It was noted that Ms Breen was the new COO for the Trust and that improving data and IT system would be an important priority for her.
7.4 Dr Ryan and colleagues replied to detailed questions from the Members and during the discussion the following points were noted:
Problems with appointment systems
(i) The Clinical Support Services CAG in the Trust had taken on the outpatient quality issues. Issues of concern ranged from the appointment follow-up system, multiple letters being issued, patients being booked in to sites on days when a clinic wasn’t operating, or patients receiving two appointments on the same day at different sites. The processing time for patients was at 14 days and reducing as were the number of missed appointments and the phone waiting times. At Royal London the out-patients service had been successfully moved to a new building which had also helped.
(ii) Major problems experienced at Whipps Cross over the summer, when a serious incident had to be declared, were now being addressed in the new ‘Millennium’ IT system. The quality of the estate at Whipps for out patients also needed addressing and a lot more work needed to be done.
(iii) The problem of multiple letters arose from lack of sufficient staff training on the new system and the need to respond robustly when patients changed their appointment times more than once. The Chair commented that it appeared that sufficient testing did not appear to have been carried out on the new system before it had gone live. It was agreed that the new problem was a transformational change one and not just an IT issue.
National Surgical Audit Results
(iv) In relation to the issue of some surgeons not carrying out optimal numbers of particular surgical procedures, the Trust now had fewer vascular surgeons, going down from 13 to 5, who were highly specialised clinicians and the outcomes had improved significantly. With stroke patients for example surgeons could now intervene at an earlier stage of a clot and thus prevent the stroke from developing. This team were also working on this issue with clinicians at the Homerton.
Concerns from C&H CCG on quality
(v) Dr Ryan had attended the September Board meeting of City and Hackney CCG to discuss their concerns in detail. Other CCGs had also been raising similar concerns. A key area of focus was to reduce the Referral to Treatment times down from the 18 week maximum. The critical measures were the ‘18 week admitted pathway’ and ensuring no more than 8% waiting longer than this. Noted that because of complexity of some cases this target would never reach 100%.
(vi) There were significant data quality issues and the Board was determined to tackle the confidence issues arising from these and to ensure that they had robust practices in place to ensure there would be no harm caused arising from delays.
(vii) As an illustration of the challenge the Trust currently had 13000 waiting for surgery and this number should be c. 7000 therefore the Trust needed to maximise every opportunity to treat people in whatever way possible.
Use of private providers
(viii) As part of this they were maximising their relationships with private providers and working with them to get waiting times down. The National Tariffs here worked against Trusts and in effect compromised their business model, in that if they treated a particular category of patients beyond the tariff threshold, they would only receive 30% of the tariff. The Trust operated within a very tight margin so often it was in their interest to have patients treated privately so as to avoid tariff sanctions. The challenge with going outside however was to balance quality vs risk.
(ix) The response was to maximise what they did internally. Sometimes it was in the patients’ interests to be treated by them via private providers but for some patients e.g. complex cases it would not be appropriate and they would wait to be seen by the Trust’s consultants. Generally though they found no reduction in patient satisfaction for those using a private provider. They were monitoring performance here closely since they stared using private providers in September.
(x) In terms of safety, Dr Ryan was the GMC designated ‘Responsible Officer’ in the Trust and would ensure any private provider would have a similar post in place. Noted that Great Ormond Street Children’s Hospital success had been underpinned by their use of private providers to complement their work. It was noted that the main use of private providers at Barts was for dermatology and ophthalmology.
(xi) In relation to bed capacity in the new Cardiac Centre, this represented an increase in a capacity overall. A Member expressed a concern that the state of the art equipment in the new centre was not being used to its optimum while there were NHS waiting lists.
Discharge problems and length of stay
(xii) A key challenge was in responding to numbers coming in via A&E and the difficulty of predicting or planning for this.
(xiii) Across the three main sites the patient profile varied. In Whipps Cross the length of stay had risen significantly. Whipps had not seen an increase in admissions but the pressure instead caused by length of stay.
(xiv) That numbers overall had not increased sharply was testament to the improved partnership working between the CCG and the Council on initiatives to keep people out of A&E but generally patients were older and with more complex needs and so discharge plans were complicated. The discharge process currently included a 40 page assessment form, such was the complexity…
(xv) The Royal London’s length of stay rate had increased and pressure continued on tertiary services. Peaks in trauma admissions which happened on occasion put great pressure on managing capacity. Despite Royal London being a major trauma centre, a night with 8 trauma calls or multiple stabbings can seriously throw out the performance figures and blockages can back up through critical care.
National Cancer Patient Survey Results
(xvi) On the Trust’s poor performance in the National Cancer Patient Survey it was noted that the Board and the Quality Committees in the Trust had spent much time studying these findings. The challenge was to manage the holistic needs of the patients.
(xvii) Outcomes were best when patients had a Clinical Nurse Specialist in place. Noted that in the past the Trust often had over complicated the treatment pathway and had 30-line action plans when the cause of the problem might have been more fundamental.
(xviii) Noted that the Friends and Family test is ward specific which did provide some more granular data. At present a large focus was on inpatient support and on A&E. A Member pointed out that a key area of concern was linking services in the hospital with local services and this pathway had not been effective at Whipps Cross. Also for the more common cancers much of the treatment was at local sites rather than at Barts and the pathways needed to be robust at each site.
(xix) Noted that Ocular cancer surgery was not being decommissioned at Barts. Barts would lead with specialist treatment at their site with additional support from Moorfields. High quality scans could be shared electronically between the two sites now avoiding the need for patients to travel between sites.
MRSA and CD
(xx) There had been 7 recent cases of MRSA which was to be regretted. They were aware of the causes which include hand cleaning, keeping environment clean, proper handling of drips and screening patients fully. A common factor in the cases here was that drips were not being used properly. Regular audits of wards were now taking place to ensure there were no lapses in procedures and disciplinary procedures were instigated against those who were not complying fully with the proper procedures.
(xxi) On Clostridium Difficile there was good news to report and there had only been 2 cases this year. They were doing root cause analyses to understand why results on CD had been good while those on MRSA had been poor.
(xxii) There had been negligence payments in the past 12 months relating to MRSA and CD but some of these claims went back some time because the more complicated cases took a long time to settle. The overall trend however on the number of claims was stable.
7.5 The Chair asked if INEL members could visit the new Cardiac Centre and officers agreed to liaise with the Overview and Scrutiny Officer to set this up. It was noted it would need to take place before Christmas to avoid some further building work which would be taking place.
ACTION: |
O&S Officer to fix date for site visit to Barts Cardiac Centre in mid-December. |
7.6 The Chair thanked Dr Ryan, Ms Breen and Mr Graver for their report and for attending to answer their questions. She commended the level of detail in the report and their constructive engagement with the work of the Committee.
RESOLVED: |
That the report and discussion be noted. |
Supporting documents:
- 1-8320082-item_7_cover_sheet_-_Barts_Health, item 7. PDF 48 KB
- MS ppt - 1-8323108-item_7_Barts_Health_presentation, item 7. PDF 480 KB