Minutes:
Fiona Wheeler, Acting Executive Managing Director – Princess Royal University Hospital and South Sites (“Acting Executive Managing Director”), Debbie Hutchinson, Director of Nursing – Princess Royal University Hospital and South Sites (“Director of Nursing”) and Sarah Middleton, Head of Stakeholder Relations – King's College Hospital NHS Foundation Trust provided an update on progress in a range of areas across King’s College Hospital NHS Foundation Trust.
The Acting Executive Managing Director informed Members that the Trust’s four hour target in Emergency Departments had been a struggle to deliver at the Denmark Hill and PRUH sites. However the PRUH had made considerable improvements, and in February reached 70% of the 95% target. The referral to treatment time remained as a priority improvement area for the Trust. The Trust was 77% compliant in relation to the number of patients waiting 18 weeks, but there were considerable problems in meeting the 52 week target. However, work way underway to reduce the backlog of more than 200 patients.
In relation to the Trust’s finances, the Trust’s control total had been agreed with their regulator for 2019/20. The financial position remained very challenging, with a reported deficit of £147m at the end of month nine. The end of year report on the Trust’s financial position was currently being completed and would be shared once it was available. Improving the performance of the Trust and the experiences of patients was difficult in the current financial climate and forward planning for this would be conveyed at future Sub-Committee meetings. In terms of quality, overall the Trust’s performance against patient outcomes remained good, and was in the top quartile for Hospital Standardised Mortality Ratio (HSMR). The Care Quality Commission had recently visited the PRUH and Denmark Hill sites, and the outcome of the inspection was awaited. The Trust was also finalising their quality priorities for 2019/20, which would be published once they were signed off by the Board.
There had been a number of new people welcomed to the Board, including Dr Clive Kay – Chief Executive, Sir Hugh Taylor – Interim Chairman and Nicola Ranger – Chief Nurse and Executive Director of Midwifery. Dr Shelley Dolan was now the Acting Deputy Chief Executive and Bernie Bluhm was Interim Chief Operating Officer for King’s College Hospital, Denmark Hill site. The Acting Executive Managing Director advised members that she was now also a member of the Trust’s Board, as her appointment had been made following the acknowledgment that the PRUH and South Sites needed Board level attention. It was noted that there were a number of Acting and Interim roles, which was to allow the new Chief Executive to consider the structure he would like in place for the governance and management system. Work was ongoing to refresh the Trust’s strategy, and the strategic framework was its current focus. A number of engagement sessions had been undertaken with staff, members and volunteers relating to what they do, why they do it and what they wanted to do in the future. Around 400 people had been engaged with so far, and further internal work would take place before the strategic framework was finalised. This had been carried out in tandem with the Board developments, and had been an open and transparent process.
In addition to the appointment of the Acting Executive Managing Director, the senior leadership team for the PRUH and South Sites included three senior team members: Meredith Deane – Director of Operations, Debbie Hutchinson – Director of Nursing and Prakash Sinha – Medical Director. Two additional roles to strengthen operational leadership had also been added in underneath the Director of Operations. The Deputy Director of Operations – Planned Care and Director of Operations – Urgent Care were two senior management leads which had been added to ensure that all objectives were being delivered.
Emergency performance was a focus at the PRUH, and meeting the four hour waiting target in A&E remained very challenging. The PRUH had seen a significant improvement in mid-March 2019, when they hit 82%. The overall performance data for March 2019 was currently being analysed and would be available shortly. Work was being undertaken with Hunters to support improvements, of which key areas of development included the rapid clinical assessment of all patients. The ambulatory flow at the PRUH was also an area of development, and it was suggested that a presentation could be made to a future meeting of the Sub-Committee, detailing step by step the emergency flow from when a patient entered the hospital, to them leaving. The underlying objective was to provide a safe service to patients whilst improving the waiting times.
The Director of Nursing informed Members of the progress on transformation and Getting It Right First Time (GIRFT). GIRFT was a national programme, led by the Clinical Leadership side of NHS England. It was designed to improve medical care within the NHS by reducing unwanted variations. There had been significant improvements to theatre productivity and the length of stay in Orthopaedics and improvements in the recorded time that theatre starts in Trauma at the PRUH. In response to a question, the Acting Executive Managing Director said that theatre utilisation had an improved trajectory of 75% to 80% and was its data looked at during performance meetings. Kings College Hospital had a higher level of assessment of theatre utilisation which was reported monthly at Board level.
Members were informed that the ‘King’s Way for Wards’ was an accredited quality improvement initiative for hospital wards. The wards were accredited on a red, amber and green system, and the assessment was inclusive of the nursing team and multidisciplinary team. This week the first two wards, Surgical 4 (PRUH) and Bodington (Orpington), had successfully completed the programme and received their green accreditation. The other wards currently working through the programme were Medical 8, Chartwell Wards, Critical Care / ICU and Coronary Care, and it was felt to be a real motivational factor for staff.
The Acting Executive Managing Director said that the Trust was currently working with system partners on admissions avoidance, which would include assessments around frailty and gaining an understanding what a patient had come in for. It aimed for an earlier discharge into community healthcare settings, which would involve ensuring that the time a patient spent on a ward was optimised in terms of decision making and reducing wastage or delays. Another area of work was the transformation of Outpatients and looking at new ways of working. The current method meant that following a visit to hospital, a patient would often have to return at a later date, only to be told that they were fine. Instead consideration would be given to looking at the new technology available and how these appointments could be delivered in different ways. An audit was being undertaken to consider the scale of demand for IV therapies to take place in the community, and to scope a service with the aim to reduce the length of hospital stays.
The Director of Nursing noted that following feedback from patients, staff and GPs, there had been a lot of focus on how patients were discharged from hospital. A new discharge lounge had opened at the PRUH in December 2018 and was now located in a bigger space at the front of the hospital. It was close to patient transport and felt to be easier for relatives and carers to find. It was a patient-friendly space with seating and a four bed / stretcher area, and had been designed to allow for a dedicated nursing care provision. It was a positive improvement and a patient information leaflet would be developed to support it.
The Acting Executive Managing Director was pleased to report that compared to last year, there was a much improved picture in relation to Norovirus cases. There had been significant progress made in reducing its spread, with less than 40 cases this year, compared to 133 cases last year. The introduction of on-site testing had made a huge difference in identifying positive cases quicker, isolating and treating them. From the data on trends collected last year, there was a clear relationship to out of hours working, and work had been undertaken to strengthen out of hours arrangements. This included collaborative working with cleaning services and senior nursing staff being on site out of hours to facilitate decision making. More effective cleaning and supervision of cleaning services had seen standards really improve, and allowed problems to be rectified quickly. Improvements had also be aided by the introduction of electronic stool charts which facilitated reporting and decision making in relation to the cohorting and isolation of patients identified.
The challenging ward layouts at the PRUH had been recognised by the regulator, NHS Improvement, and as a result over £100k had been secured for estates work. The current ward layouts did not help with infection control as there was a high level of footfall travelling through them. Work was underway to segregate the wards which included removing touch points to reduce the infection risk, additional doors, updates to the sluices and intercom systems and the installation of additional hand wash basins. A Member noted that there was a statement on the hard copies of menus on the wards, advising that they should be left for the next patient, and suggested that these should actually be removed and disposed of. The Director of Nursing responded that this would be taken back, and noted that work needed to be undertaken to support patients with washing their hands before and after eating. There was more to learn, but it was much improved and these changes were making an impact.
The annual staff survey results for 2018 had been published for all Trusts in February 2019. The Trust had an engagement score of 6.8 against the national average of 7, and it was noted that the PRUH and South Sites engagement score was 6.9 and one of the most engaged divisions of the Trust. In response to a question, the Acting Executive Managing Director advised that there was not a London benchmark for the scores.
The PRUH and South Sites had scored well in areas that included providing a safe environment for staff, for which they had undertaken a huge amount of work delivering training to deal with violence and aggression and installing alarms. Other areas that scored well were equality, diversity and inclusion, for which the Trust had a well communicated strategy; and quality of care, as staff were hugely proud of the service they provided. Areas for improvement were highlighted as being health and wellbeing, the quality of appraisals and morale. Improvements to health and wellbeing would involve looking at the support provided and peripheral services offered. In relation to appraisals, the score was high in terms of compliance but the depth and quality could be improved. In response to a question, the Acting Executive Managing Director said that the appraisals referred to were non-medical appraisals, and that the number completed had increased since the new system had been implemented which was now linked to mandatory training. The quality of the appraisal was only as good as the person appraising, and they needed to be trained and empowered to do so. It was noted that the low score for morale was a reflection of not just the PRUH, but the rest of the Health Service. It was noted that the media did not reinforce positivity, and that morale was needed on two levels – to motivate, and to recognise that the NHS was a tough environment to work in.
Feedback on patient experience between September 2018 and February 2019 had resulted in an overall Friends and Family Test score of 89% of patients recommending the services at the PRUH and South Sites. There had also been experiences rated as excellent on many wards, including Medical 1, Medical 2, PRUH Coronary Care and Chartwell. The Emergency Department and Outpatients had not scored as highly, and feedback indicated that patients did not feel involved in their care.
A Member questioned how a Trust that was so large and busy could have such a big financial deficit. The Acting Executive Managing Director responded that the entire deficit had not just accumulated over the last year, and that there were a number of factors that had influenced it. It was suggested that the Trust’s Chief Finance Officer could attend a future meeting of the Sub-Committee to deliver a detailed financial summary.
In response to a question, the Acting Executive Managing Director said that as part of the improvement plan, a range of things had been implemented in order to cut down waiting times. These included rapidly assessing patients when they entered the department, and through the hospital to be discharged sooner. Delays into the evening had lessened and lots of disciplines were involved to work on specific areas, how to access other services and make decisions as to what happened next in terms of a patients’ care. It was suggested that the Trust’s Clinical Director could attend a future meeting of the Sub-Committee to provide an update.
In response to a question from the Chairman, a Co-opted Member stated that some issues that he had raised previously were still ongoing, and it was agreed that a conversation with the Acting Executive Managing Director would take place outside of the meeting.
The Chairman thanked Fiona Wheeler, Debbie Hutchinson and Sarah Middleton for their excellent presentation, which had provided a very honest insight into what was happening within the Trust. A copy of the presentation was attached to the minutes at Appendix A.