Agenda item

Please note that this item will be considered as the first item on the Health Scrutiny Sub Committee Agenda. That meeting starts at 3.30pm.  Board Members will be joined by their committee colleagues for this item.  After which Board Members can leave whilst the Scrutiny committee continues with its agenda.

This item will include:

• Winter Pressures Update;
• Outcome of the meeting with Monitor in November;
• Outcome of the recent CQC inspection;
• Joint working to improve outcomes;

For consideration of this item the Board was joined by colleagues from the Health Scrutiny Sub-Committee (HSSC).

The Chairman of the HSSC made a statement: 

I was greatly disappointed to learn on Monday morning that a summit had been arranged for today that Kings’ would be attending and they would not therefore be present here to address this committee and members of the public to allay their concerns regarding The PRUH.

Staff here notably Angela Buchanan, did their utmost at this incredibly short notice to try and accommodate the meeting here at The Civic Centre, so that both Agendas’ could be addressed. Kings’ refused our efforts.

Staff in Care Services are already faced with an extremely heavy workload and it is not right that they had to spend valuable hours dealing with something that could have been avoided. I understand that the Portfolio Holder drew the date of today’s meeting to their attention as early as 17^th January 2014.

If we are going to successfully work together and give confidence to the residents of Bromley with regards to the health service, we need reassurance from Kings’ that this situation will be avoided in the future.

Moving forward, we need Kings’ to provide a full update on the impact their plans/changes have had on The PRUH, especially with regard to A&E performance and trolley breaches.

I am not prepared to spend valuable resources convening a separate meeting, so would ask with plenty of notice that all parties’ concerned attend the next Care Services PDS on March 11^th to provide this in a special item

I will be writing to Kings’ to express the views of this committee regarding this meeting.

The Board and Members of the Health Scrutiny Sub-committee had raised concerns regarding the performance of the Accident and Emergency Department at the Princess Royal University Hospital (PRUH) for some time.  The performance at the Hospital over the last quarter had been at levels below the agreed performance level, with some very significant daily and weekly fluctuations.

There were various steps in place to help improve the performance in order that it was brought back in line with the agreed trajectory.  The CCG presented a briefing paper outlining, broadly the position in line with the trajectory in the previous quarter, highlighting some of the causes for the decline in performance in the previous quarter as well as describing current and planned actions.

Dr Bhan, from the CCG addressed Members. She had conveyed Members feelings about King’s failure to attend and apologised that the situation had arisen.

She reported that the target for A&E patients was that 95% of patients should be in the department for no longer than 4 hours before they are either moved to a ward or discharged. This would only be achieved if all departments were functioning efficiently.

Dr Bhan then outlined the previous history of the PRUH prior to the takeover by King’s. However even after the takeover the performance of A&E had not reached the 95% target and since December 2013 it was clear that the trajectory was not going to be met.  It had been recognised at the outset that it would take some time before the hospital was able to meet the targets and the CCG therefore agreed with King’s a lower trajectory of 87% for quarter 3 had 90% for quarter 4 of 2013/14. This was also agreed with monitor and NHS England as being realistic.

In addition there were a large number of trolley breaches. Both the CCG and King’s found this unacceptable and were working hard with all agencies and community services to avoid future breaches.

There were a number of vacant posts at the hospital and King’s were recruiting to fill vacancies; Advertising for additional staff meant there were now 2.6 fulltime equivalents (FTE) matrons in A&E, 3 new consultants and additional nurses.  Further recruitment was still needed.  Where appointments could not be made King’s employed agency staff.

Improvements were also needed in patient pathways as there had been a decline in numbers and the system was becoming “disjointed”. The reporting system had been improved as the previous system had not been clear when reporting the percentage of patients waiting longer than 4 hours in A&E.

Changes in the way facilities were used had seen a number of Queen Mary’s patients being treated for elective procedures at the PRUH and a number of services were now linked; such as the Post Acute Care Enablement (PACE) Service provided by Bromley Healthcare.

Dr Bhan explained that action was being taken to recover the overall situation and there had been “shoots of improvement”; during the previous weekend over 90% of patients were seen within 4 hours. 

She then outlined an exercise the hospital would be undertaking; “The Perfect Week”. The hospital put itself in the position of dealing with a major incident.  The exercise had been undertaken recently for 10 days at King’s College Hospital and had seen performance reach 96%. As there was so much work at the PRUH it was decided to wait until after the changes had taken place and was therefore scheduled for the end of February.

Members then debated the item and asked questions; The HSSC Chairman asked if Social Workers were now working at the hospital at the weekends and the Director confirmed that they had always been available at the weekend or were on call.  He added that he was aware there were still problems at the PRUH, one of which was no uniform system for discharging patients and this was more apparent at the weekends.

He re-iterated the hospital was understaffed but added that he could not fault the work Dr Bhan had achieved as a Chief Officer for the CCG even though it was not her role.

Dr Bhan explained that the crisis at the PRUH was acute and that there was a crisis support unit which provided daily updates. One particular issue was looking at patients who were medically or surgically fit but were not being discharged.  The unit also talked to patients to ascertain their views on why they were being delayed.  In addition a detailed weekly report on trolley breaches and breaches of the 4 hour A&E targets was provided and Dr Bhan agreed that this information could be shared with the Board.

Members asked what the CCG was doing to involve GP’s and Dr Bhan explained that GP’s were commissioned by NHS England not the CCG but it was working with them to try to encourage patients to consider other routes for treatment rather than A&E; such as GP visits, talking to a pharmacist and using the Urgent Care Centres. 

One Member asked how many staff had been lost at the PRUH and also sought clarification regarding reports of patients having to wait in ambulances as the A&E departments were too full to accept them. He also asked about GP’s working at the hospital and the role of the Urgent Care Centres.

In response Dr Bhan explained under the South London Health Trust (SLHT) there had been a gradual reduction in staff and King’s was now seeking to recruit an additional 200 staff across all areas both clinical and non-clinical. She confirmed that Beckenham Beacon had both a walk in centre and a minor injuries unit.  An Urgent Care Centre was based at the PRUH staffed by GP’s and consideration was being given to expanding this service.

In response to ambulance delays Dr Bhan explained that ambulance crews would divert to another hospital if one was at capacity.  In addition if there were too many delays the service would send an Ambulance Manager to review the situation.

Concerns were raised about discharging patients too early, particularly vulnerable patients such as those suffering with dementia.  Many were looked after by elderly carers.  Dr Bhan said that it was not the hospitals intention to discharge patients before they were ready.  As part of the “Perfect Week” exercise no-one would be discharged without a carers and a home assessment.  She said she was happy to investigate individual cases if Members had concerns.

One of the areas that Members felt caused a delay in discharge was waiting for medications as the pharmacy appeared to be very slow.  Dr Bhan reported that this was being addressed, it wasn’t necessarily a problem at the pharmacy it was also a case of having to wait for a junior doctor to sign prescriptions. The Chairman of the HSSC asked for regular updates on this.

Members then asked about staff morale at the PRUH and were informed that King’s was taking steps to raise morale.  This included training and opportunities for staff. It was noted that morale would improve as performance increased.

Dr Bhan was unable to answer questions on patient transport, which King’s commissioned on behalf of the CCG.  It was agreed that a report on patient transport would be brought to the meeting of the Care Services Policy Development and Scrutiny Committee in March.

When considering how to reduce the demand for emergency services, many of the people were elderly and such patients could deteriorate very quickly.  One Member suggested that care homes should be able to prescribe antibiotics.  Dr Bhan explained that there could be a problem with this and that all care homes had a visiting medical officer, usually a GP from the nearest practice. However she did acknowledge that more training was needed for care home staff to help them manage residents’ health.

Members enquired about the numbers of out of borough residents who accessed the A&E department at the PRUH.  Dr Bhan explained that the import/export ratio was about even.  Bromley residents in the north and north west of the borough were closer to Lewisham or Croydon University hospitals so tended to go there.  She also reported that the majority of Bexley residents tended to use Darenth Valley hospital or Queen Elizabeth Hospital.

Linda Gabriel, Healthwatch Bromley reported that they had set up some focus groups in autumn 2013.  The issues raised included cleanliness and hand washing.  Discharge of patients was also an issue and delays in writing up patients notes.  Healthwatch was intending to do an “enter and view” at the PRUH.  This had been scheduled for early February but the hospital asked if this could be delayed and so it was now scheduled for mid March.  She would report on progress at the next meeting.

In relation to winter pressures Dr Bhan reported that there had been a monitoring meeting and all agencies were working collectively to provide one point for information.  She was pleased to report that winter pressures had not been as bad as in previous years.

RESOLVED that the report be noted.