Agenda item

Following the conclusion of an investigation into financial issues at the Princess Royal University Hospital (PRUH), Monitor had published a statement of Enforcement Undertakings and a public statement. Monitor had agreed with King’s that the Trust would develop and implement a short term recovery plan  and a longer term plan to ensure that services were improved and provided in a sustainable way in future. Monitor had declined to attend the Sub-Committee’s meeting due to the purdah restrictions, but had offered to attend the next meeting.

Roland Sinker, Chief Operating Officer and Acting Chief Executive of the Kings College Hospital NHS Foundation Trust and Sally Lingard, Director of Communications, attended the meeting. Mr Sinker gave a presentation on King’s involvement with the PRUH. The presentation focussed on –

• The PRUH at acquisition in October 2013 – There was a high vacancy rate, poor emergency pathway performance on a downward trajectory, a low incident reporting rate, low rates of delivery on the continuous improvement plan, areas of concern in various services and issues with medical leadership in some areas. 

• Progress to date – Vacancies had been reduced to less than 10%, an elective orthopaedic centre had been developed at Orpington Hospital, “how are we doing” scores had been improved and complaints at the PRUH reduced, incident report rates had doubled, the Hyper Acute Stroke Unit had improved to 18^th position (of 180), the huge backlog in radiology had been addressed and quality had been prioritised over financial performance. The Trust had ended the year with a deficit of over £47m.

• Areas for further work – These included developing partnerships with stakeholders across South East London, whole-system changes of the emergency pathway and referral to treatment times (RTT), improving the staffing establishment, especially in the emergency department and acute care and in neurology, addressing areas of concern such as fractured neck of femur (NOF) and medical records and delivering the financial plan.

• Monitor Investigation – King’s had welcomed the assistance of Monitor to move the Trust into financial sustainability, improve emergency pathway performance and tackle Referral to Treatment; a one year emergency recovery plan needed to be agreed by the end of May, and a longer term 5 year plan by the end of October, but the Trust would have to ask the Department of Health for extra financial assistance in May.

Mr Sinker then answered questions from the Sub-Committee and made the following comments –

• There were three elements to improving quality – patient safety, patient outcomes and patient experience, and of these the latter was the most problematic.

• Mr Sinker was not able to provide details on how much of the £47m deficit was due to the cost of the PFI for the PRUH, but the Trust had received additional funding to reflect the higher costs of this early PFI deal compared to later PFIs. He later explained that the government had funded the difference between early and late stage PFIs when the Trust had acquired the PRUH and payment by results tariffs included payments for early-stage PFIs.

• The Trust faced challenges recruiting nursing and other staff with its proximity to Lewisham and central London.

• Mr Sinker promised to improve provision of performance figures for individual facilities, such as the PRUH, as opposed to Trust-wide figures.

• Responding to comments from a Member, Mr Sinker admitted that the situation had changed since the autumn of 2014, when there had been considerable optimism and the budget appeared to be under control. The Emergency Department had been making good progress, but a key member of staff had left and the service had “fallen over” in October 2014. This reflected nation-wide problems that saw emergency care pressures increase through the winter months, but the PRUH had been particularly fragile.

• Hospital acquired infection rates had seen a considerable decrease since 2005, and the numbers of cases were very low.

• Theatre utilisation rates at the PRUH (sometimes under 60%) still lagged behind Denmark Hill (75-80%.) Work was needed to make the PRUH a centre for high performing day surgery, with more complex patients dealt with at Denmark Hill. A balance of different factors such as increasing beds on the PRUH site, making the hospital work faster and more prevention work was needed. He also commented that it made sense to consolidate different services on particular sites, concentrating expertise, but he accepted that there was resistance from consultants and from the public to this. A Member commented that this was a political issue, and that there had been some success in persuading people that services for heart disease and stroke should be concentrated in centres of excellence.  

•  A Member commented that although clinical care at the PRUH was good, the peripheral services were often poor, including systems and management culture. There were problems with timeliness and  dependence on agency staff (she suggested a return to providing nurses homes to overcome the increasing costs of accommodation.) Mr Sinker acknowledged these issues, and stated that the Trust was attempting to turn things around, but this was a long-term project that would take five years.

• Asked whether overall capacity across south east London was adequate, Mr Sinker admitted that there were other parts of the country where capacity pressures were not so severe.

• A Member commented on waits of 18 months for orthopaedic surgery – Mr Sinker requested details so that he could investigate.

• Mr Sinker stated that there was prioritisation of patients with serious conditions, but this was not the same as rationing services.

• The Trust’s  £47m annual deficit was part of a national problem, with over 50% of foundation trusts now in deficit.

• A Member commented that having spent considerable time persuading people that Orpington Hospital was unsafe and should close, the NHS had now reversed this. Mr Sinker did not know the full history of the site, but he did explain that creating a critical mass of services there was the right approach – the Trust had Orpington Hospital for at least three years and the site was now being well-used. Sally Lingard confirmed that orthopaedic results at Orpington were excellent with better outcomes than at the PRUH or Denmark Hill. Dr Angela Bhan added that there were two major factors in making Orpington Hospital a success – the investment in the fabric of the building from Kings and the increased numbers of patients passing through. There was therefore a strong case for keeping Orpington Hospital open.

• A Member commented that she could understand how consultants were resistant to further relocations of services when this might be their third or fourth move. Each move cost money and more stability was needed – a strong business case was needed for each relocation of services. Mr Sinker agreed that services should not be moved without good reason, but he felt that further consolidation was needed. He also wanted to drive productivity at the PRUH, providing additional beds on-site, and provide more tertiary services at Denmark Hill.

• Responding to a Member’s comment that GPs appeared to be doing less diagnostic work, Mr Sinker commented that the Trust had not seen a massive increase in patients being referred.

• Asked about the hydrotherapy pool at Orpington, Mr Sinker confirmed that it was a very useful facility with synergies with the orthopaedic services now at Orpington and there were no plans to close it.

• Asked about the Monitor review, Mr Sinker stated that, although he could not be sure at this stage, he expected the recovery plan to be signed off by Monitor. Kings was now aiming for a cost improvement of 8%, when other trusts were seeking 4-5%, but he still expected to have to ask the Department of Health for cash support at least twice this year.

Sally Lingard announced that the Trust were keen to arrange a visit to the PRUH and Orpington for Committee members.  

The Chairman thanked Mr Sinker and Ms Lingard for attending.